Multiple spinal surgical pathways systems and methods

ABSTRACT

A method facilitates the treatment of the spine of a patient by providing simultaneous access through at least a first opening and a second opening formed in the patient. For example, the method can include the acts of positioning the patient on a surgical table, providing the first opening into a posterior portion of the patient, providing the second opening into a lateral portion of the patient, inserting a first device through the first opening into the patient to contact the spine in a first direction that is transverse to the coronal plane of the patient, and inserting a second device through the second opening into the patient to contact the spine in a second direction that is transverse to the sagittal plane of the patient, where the first and second openings are accessible simultaneously, and, when the first and second devises are inserted into the patient, the position of the patient is stationary with respect to a portion of the table.

The present application is a continuation of U.S. application Ser. No.15/618,302, filed Jun. 9, 2017; which is a continuation of U.S.application Ser. No. 14/694,802, filed Apr. 23, 2015; which claimsbenefit of Provisional Application No. 62/021,490, filed Jul. 7, 2014;all of which are incorporated by reference herein.

TECHNICAL FIELD

The present disclosure generally relates to medical devices for thetreatment of musculoskeletal disorders, and more particularly to asurgical system that utilizes multiple surgical pathways to manipulateand surgically treat the human spine.

BACKGROUND

Since the late 1800s, orthopedic surgeries have been performed tocorrect and stabilize patients' bony anatomy. While the majority oforthopedic surgeries continue to be performed on knees and hips,procedures on the spine have been increasing since the 1980s, and thenumber of approaches and procedures continues to expand. Rods, plates,screws, hooks, and interbody fusion spacers are examples of implantscurrently used align and stabilize patients' spines to address issueswith deformity (such as scoliosis), tumor, trauma, or degenerativeconditions.

Initially, surgeons treated their patients from a single incision, witha posterior approach. In this orientation, the patient may be positionedprone (on his/her stomach) and the surgeon makes an incision in theperson's back. Corrections were made using instruments and implants fromthat approach, the implants were inserted and/or locked in place, andthe incision was closed.

Not long after, anterior approaches started to be utilized. In ananterior approach, the patient may be positioned supine (on his/herback) and an incision is made in the abdomen, in line with where thecorrection needs to be made. This approach creates new challenges,because in a posterior approach the surgeon is just traversing muscletissue, but in the anterior approach the surgeon is working near/againstthe patient's internal organs and vascular structures. The advantage ofthe anterior approach is that the anterior column of the spine is theprimary load-bearing member, and addressing the anterior side directlyis thought to allow the surgeon to impart greater correction than via aposterior-only approach.

A lateral approach has also been considered and used. In a lateralapproach, the patient is typically positioned in the lateral decubitusposition (e.g. on his/her side) and the incision is made approaching theanterior spinal column directly from the side, as opposed to the frontas in the anterior approach. This avoids organs, as they tend to “fallforward” and move anteriorly out of the surgeon's field. But the lateralapproach may also require addressing the psoas muscle, and within thepsoas muscle are housed a bundle of nerve fibers that should be avoidedto minimize post-operative complications. Therefore, the lateralapproach was not used often until the advent of neural integritymonitoring, which allows the surgeon to monitor via electronic equipmenthow close they are to these nerves during the lateral approach. Thelateral approach has physiologic limitations as well—ribs and the pelvisprevent easy access to levels beyond the upper lumbar region or belowthe third or fourth lumbar vertebra. However, the ability to place alarge load-bearing interbody implant has made the lateral procedureappealing, despite its challenges.

Most recently, an oblique approach has been utilized. The patient maystill be positioned laterally, but rather than a true lateraltrajectory, the surgeon approaches the anterior from an oblique angle,or “tilted” towards the anterior spine. This allows access to theappropriate discs, yet avoids contact with the psoas (and hidden neuralstructures) while still avoiding conflict with the internal organs.

Finally, any of the above procedures might be used together incombination. For instance, the surgeon could perform an Oblique LumbarInterbody Fusion (OLIF) procedure, thus providing a large anteriorsupport structure using an interbody implant, then perhaps follow upwith a posterior procedure to provide greater overall stability viaposterior implant instrumentation. The surgeon could similarly coupleany combination of procedures to accomplish treatment goals in aparticular patient. Various approaches to the anterior spine can also beused in combination. For example, because direct lateral exposure doesnot allow for easy access to the lumbosacral junction (the disc betweenthe lumbar spine and the sacrum or the L5-S1 space) the surgeon couldperform an oblique or anterior approach to access that level, and thenuse direct lateral on the higher (superior) levels. In any event, inorder to combine approaches, the surgeon currently has only two choices:reposition the patient during the procedure (while he/she is underanesthesia) or perform separate procedures in series (called “stagedprocedures”). In the first option, the length of surgery is extended,which is not preferable due to the desire to limit the amount of timethat the patient is under anesthesia, and due to Operating Room (O.R.)operational costs added by the delay. Staged procedures may cost more,and typically involve increasing the patient's time in the hospital dueto the multiple procedures. The changes in healthcare and/orimplementation of the Affordable Healthcare Act (ACA) will likely affectthe ability of the surgeon to choose particular combinations as well,given the drive towards cost containment and evidence-based medicine.

Therefore, there remains a clinical need in many cases for the surgeonto be able to utilize several different surgical approaches to the spineeither substantially simultaneously or at the very least, during thesame procedure. Furthermore, there exists a need for methods andapparatus that allow a surgeon more efficient and efficacious optionsfor treating a patient using several approaches.

SUMMARY

The present invention in one preferred embodiment contemplates a methodfor surgically treating a spine in a patient is provided that includesinserting a first device through a first opening using a first approach;and inserting a second device through a second opening using a secondapproach while the first device is inserted through the first opening,where the first approach is different than the second approach.

The present invention in another preferred embodiment contemplates amethod for surgically treating a spine in a patient is provided thatincludes performing a first surgical procedure with the patient in asurgical position; and performing a second surgical procedure withoutmoving the patient from the surgical position, where the first andsecond surgical procedures are each selected from a group consisting of:discectomy, laminotomy, laminectomy, direct decompression, indirectdecompression, cutting an anterior longitudinal ligament, implantinsertion, trial insertion, distraction of vertebrae to ease implantinsertion, distraction of vertebrae to facilitate disc removal,distraction of vertebrae to facilitate visualization and creation of afulcrum, and where the first surgical procedure is different than thesecond surgical procedure.

The present invention in yet another preferred embodiment contemplates amethod for surgically treating the spine of a patient that includespositioning a patient on a surgical table, providing a first openinginto a posterior portion of the patient, providing a second opening intoa lateral portion of the patient, inserting a first device through thefirst opening into the patient to contact the spine in a first directionthat is transverse to the coronal plane of the patient, and inserting asecond device through the second opening into the patient to contact thespine in a second direction that is transverse to the sagittal plane ofthe patient, where the first and second openings are accessiblesimultaneously, and, when the first and second devises are inserted intothe patient, the position of the patient is stationary with respect to aportion of the table.

The present invention in still another preferred embodiment contemplatesa method for surgically treating the spine of a patient that includespositioning the patient on a surgical table, maintaining a position ofthe patient with respect to the surgical table during surgery, while theposition of the patient is being maintained, simultaneously accessing afirst opening and a second opening in the patient during the surgery,the first opening affording access to a posterior portion of thepatient, and the second opening affording access to a lateral portion ofthe patient, where accessing the first opening includes inserting afirst device into the patient to contact the spine in a first insertiondirection that can be from 45 degrees to −45 degrees with respect to asagittal plane bisecting the patient, and where accessing the secondopening includes inserting a second device into the patient to contactthe spine in a second insertion direction that can be from 45 degrees to−45 degrees with respect to a coronal plane passing through the spine ofthe patient.

The present invention in yet still another preferred embodimentcontemplates a method for surgically treating the spine of a patientthat includes simultaneously accessing the spine of a patient through afirst opening and a second opening in the patient during surgery, thefirst opening being through a posterior portion of the patient, and thesecond opening being through a lateral portion of the patient, while thefirst and second openings are being accessed, maintaining a position ofthe patient on a surgical table, inserting a first device through thefirst opening into the patient to contact the spine in a first insertiondirection, inserting a second device through the second opening into thepatient to contact the spine in a second insertion direction, insertinga third device through one of the first and second openings to contactthe spine in a third insertion direction, and where the first insertiondirection is substantially aligned with a sagittal plane bisecting thepatient, the second insertion direction is substantially aligned with acoronal plane passing through the spine, and the third insertiondirection is substantially perpendicular to one of the first and secondinsertion directions.

It is understood that both the foregoing general description and thefollowing detailed description are exemplary and explanatory only, andare not restrictive of the invention as claimed.

BRIEF DESCRIPTION OF THE DRAWINGS

The present disclosure will become more readily apparent from thespecific description accompanied by the following drawings, in which:

FIG. 1A is a diagram showing a portion of a spine of a patient withinthe patient's abdomen and posterior, anterior, right lateral and leftlateral portions of the patient;

FIG. 1B is a top view showing the portion of the spine shown in FIG. 1Awithin the patient's abdomen shown in FIG. 1A;

FIG. 1C is a top, perspective view of the portion of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A;

FIG. 1CC is a top, perspective view of the full length of the patient'sspine depicting portions of the patient's abdomen shown in FIG. 1A;

FIG. 1CCC is another top, perspective view of the full length of thepatient's spine depicting portions of the patient's abdomen shown inFIG. 1A;

FIG. 1D is a top, perspective view of the portion of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,two incisions in the posterior portion of the patient to access theportion of the spine using a posterior approach, and one incision in theleft lateral portion of the patient to access the portion of the spineusing a lateral approach or an oblique approach;

FIG. 1E is a top, perspective view of the portion of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,the first and second incisions shown in FIG. 1D, the third incisionshown in FIG. 1D, a first device extending through the first incisionusing a posterior approach to engage a first vertebral body, a seconddevice extending through the second incision using a posterior approachto engage the first vertebral body, a third device extending through thesecond incision using a posterior approach to engage a second vertebralbody, a fourth device extending through the third incision using alateral approach to engage the first vertebral body, and a fifth deviceextending through the third incision using a lateral approach to engagethe second vertebral body;

FIG. 1F is a top, perspective view of the portion of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,the first and second incisions shown in FIG. 1D, the third incisionshown in FIG. 1D, the first device shown in FIG. 1E extending throughthe first incision using a posterior approach to engage the firstvertebral body, the second device shown in FIG. 1E extending through thesecond incision using a posterior approach to engage the first vertebralbody, the third device shown in FIG. 1E extending through the secondincision using a posterior approach to engage the second vertebral body,the fourth device shown in FIG. 1E extending through the third incisionusing a lateral approach to engage the first vertebral body, the fifthdevice shown in FIG. 1E extending through the third incision using alateral approach to engage the second vertebral body, and a sixth deviceextending through the first incision using a posterior approach toengage the second vertebral body;

FIG. 1G is a side, perspective view of the portion of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,the first and second incisions shown in FIG. 1D, the third incisionshown in FIG. 1D, the first device shown in FIG. 1E extending throughthe first incision using a posterior approach to engage the firstvertebral body, the second device shown in FIG. 1E extending through thesecond incision using a posterior approach to engage the first vertebralbody, the third device shown in FIG. 1E extending through the secondincision using a posterior approach to engage the second vertebral body,the fourth device shown in FIG. 1E extending through the third incisionusing a lateral approach to engage the first vertebral body, the fifthdevice shown in FIG. 1E extending through the third incision using alateral approach to engage the second vertebral body, and the sixthdevice shown in FIG. 1F extending through the first incision using aposterior approach to engage the second vertebral body;

FIG. 1H is a side, perspective view of the portion of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,the first and second incisions shown in FIG. 1D, the third incisionshown in FIG. 1D, the first device shown in FIG. 1E extending throughthe first incision using a posterior approach to engage the firstvertebral body, the second device shown in FIG. 1E extending through thesecond incision using a posterior approach to engage the first vertebralbody, the third device shown in FIG. 1E extending through the secondincision using a posterior approach to engage the second vertebral body,and the sixth device shown in FIG. 1F extending through the firstincision using a posterior approach to engage the second vertebral body,the fourth device shown in FIG. 1E and the fifth device shown in FIG. 1Ehaving been removed from the first and second vertebral bodies throughthe third incision;

FIG. 1I is a side view of the portion of the spine shown in FIG. 1Adepicting patient's abdomen shown in FIG. 1A, the second device shown inFIG. 1E extending through the second incision using a posterior approachto engage the first vertebral body, the third device shown in FIG. 1Eextending through the second incision using a posterior approach toengage the second vertebral body, and an interbody implant positionedbetween the first and second vertebral bodies;

FIG. 1J is a top view of the patient's abdomen shown in FIG. 1A showingpositioning of the patient's abdomen as the first device shown in FIG.1E is inserted through the first incision using a posterior approach toengage the first vertebral body, and the sixth device shown in FIG. 1Fis inserted through the first incision using a posterior approach toengage the second vertebral body;

FIG. 1K is a top view of the patient's abdomen shown in FIG. 1A showingpositioning of the patient's abdomen as the first device shown in FIG.1E is inserted through the first incision using a posterior approach toengage the first vertebral body, the second device shown in FIG. 1E isinserted through the second incision using a posterior approach toengage the first vertebral body, the third device shown in FIG. 1E isinserted through the second incision using a posterior approach toengage the second vertebral body, and the sixth device shown in FIG. 1Fis inserted through the first incision using a posterior approach toengage the second vertebral body;

FIG. 1L is a top view, in part cross section, of the patient's abdomenshown in FIG. 1A showing positioning of the patient's abdomen as thefirst device shown in FIG. 1E is inserted through the first incisionusing a posterior approach to engage the first vertebral body, thesecond device shown in FIG. 1E is inserted through the second incisionusing a posterior approach to engage the first vertebral body, the thirddevice shown in FIG. 1E is inserted through the second incision using aposterior approach to engage the second vertebral body, the fourthdevice shown in FIG. 1E is inserted through the third incision using alateral approach to engage the first vertebral body, the fifth deviceshown in FIG. 1E is inserted through the third incision using a lateralapproach to engage the second vertebral body, and the sixth device shownin FIG. 1F is inserted through the first incision using a posteriorapproach to engage the second vertebral body;

FIG. 1M is a top, perspective view of portions of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,the first and second incisions shown in FIG. 1D, the third incisionshown in FIG. 1D, the first device shown in FIG. 1E extending throughthe first incision using a posterior approach to engage the firstvertebral body, the second device shown in FIG. 1E extending through thesecond incision using a posterior approach to engage the first vertebralbody, the third device shown in FIG. 1E extending through the secondincision using a posterior approach to engage the second vertebral body,the fourth device shown in FIG. 1E extending through the third incisionusing a lateral approach to engage the first vertebral body, the fifthdevice shown in FIG. 1E extending through the third incision using alateral approach to engage the second vertebral body, and the sixthdevice shown in FIG. 1F extending through the first incision using aposterior approach to engage the second vertebral body, where the first,second, third, fourth, fifth and sixth devices are Steinmann pins;

FIG. 1N is a side, perspective view of portions of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,the first and second incisions shown in FIG. 1D, the third incisionshown in FIG. 1D, the first device shown in FIG. 1E extending throughthe first incision using a posterior approach to engage the firstvertebral body, the second device shown in FIG. 1E extending through thesecond incision using a posterior approach to engage the first vertebralbody, the third device shown in FIG. 1E extending through the secondincision using a posterior approach to engage the second vertebral body,the fourth device shown in FIG. 1E extending through the third incisionusing a lateral approach to engage the first vertebral body, the fifthdevice shown in FIG. 1E extending through the third incision using alateral approach to engage the second vertebral body, and the sixthdevice shown in FIG. 1F extending through the first incision using aposterior approach to engage the second vertebral body;

FIG. 1O is a side view of portions of the spine shown in FIG. 1Adepicting portions of the patient's abdomen shown in FIG. 1A, the seconddevice shown in FIG. 1E extending through the second incision using aposterior approach to engage the first vertebral body, the third deviceshown in FIG. 1E extending through the second incision using a posteriorapproach to engage the second vertebral body, and an interbody implantpositioned between the first and second vertebral bodies;

FIG. 1P is a top view of the patient's abdomen shown in FIG. 1A showingpositioning of the patient's abdomen as the first device shown in FIG.1E is inserted through the first incision using a posterior approach toengage the first vertebral body, the second device shown in FIG. 1E isinserted through the second incision using a posterior approach toengage the first vertebral body, the third device shown in FIG. 1E isinserted through the second incision using a posterior approach toengage the second vertebral body, the fourth device shown in FIG. 1E isinserted through the third incision using a lateral approach to engagethe first vertebral body, the fifth device shown in FIG. 1E is insertedthrough the third incision using a lateral approach to engage the secondvertebral body, and the sixth device shown in FIG. 1F is insertedthrough the first incision using a posterior approach to engage thesecond vertebral body;

FIG. 1Q is a top, perspective view of portions of the spine shown inFIG. 1A depicting portions of the patient's abdomen shown in FIG. 1A,the first and second incisions shown in FIG. 1D, the third incisionshown in FIG. 1D, the second device shown in FIG. 1E extending throughthe second incision using a posterior approach to engage the firstvertebral body, the third device shown in FIG. 1E extending through thesecond incision using a posterior approach to engage the secondvertebral body, and the sixth device shown in FIG. 1F extending throughthe first incision using a posterior approach to engage the secondvertebral body, where the sixth device is guided into position using anavigational tool;

FIG. 2A is a top view, in part cross section, of a vertebral body of apatient including a first device that is inserted through a firstincision using a posterior approach to engage the vertebral body, and asecond device that is inserted through a second incision using a lateralapproach to engage the vertebral body, where the first and seconddevices are each bone screws that are in the same plane and the firstdevice is spaced apart from the second device;

FIG. 2B is a top view, in part cross section, of the vertebral bodyshown in FIG. 2A including the first device shown in FIG. 2A insertedthrough a first incision using a posterior approach to engage thevertebral body, a second device inserted through a second incision usinga lateral approach to engage the vertebral body, and a third deviceinserted through the first incision using a posterior approach to engagethe vertebral body, where the second and third devices are each bonescrews that are in the same plane and the second device engages each ofthe first and third devices;

FIG. 2C is a top view, in part cross section, of the vertebral bodyshown in FIG. 2A including the first device shown in FIG. 2A insertedthrough a first incision using a posterior approach to engage thevertebral body, and the second device shown in FIG. 2B inserted througha second incision using a lateral approach to engage the vertebral bodyand the first device, where the first and second devices are in the sameplane and the third device shown in FIG. 2B has been removed from thevertebral body;

FIG. 2D is a top view, in part cross section, of the vertebral bodyshown in FIG. 2A including a first device inserted through a firstincision using a posterior approach to engage the vertebral body, and asecond device inserted through a second incision using a lateralapproach to engage the vertebral body, where the first and seconddevices are cannulated bone screws and the first device is spaced apartfrom the second device;

FIG. 2E is a top view, in part cross section, of the vertebral bodyshown in FIG. 2A including a first device inserted through a firstincision using a posterior approach to engage the vertebral body, and asecond device inserted through a second incision using a lateralapproach to engage the vertebral body and the first device, where thefirst device has a length that is greater than that of the seconddevice;

FIG. 2F is a top view, in part cross section, of the vertebral bodyshown in FIG. 2A including a first device inserted through a firstincision using a posterior approach to engage the vertebral body, and asecond device inserted through a second incision using a lateralapproach to engage the vertebral body and the first device, where thesecond device has a length that is greater than that of the firstdevice;

FIG. 2G is a top, perspective view, in part phantom, of a vertebral bodyincluding a first device that is inserted through a first incision usinga posterior approach to engage the vertebral body, a second device thatis inserted through the first incision using a posterior approach toengage the vertebral body, and a third device that is inserted through asecond incision using a lateral approach to engage the vertebral body,where at least one of the first and second devices are in a first planeand the third device is in a second plane that is different than thefirst plane;

FIG. 2H is a side, perspective view, in part phantom, of a vertebralbody including the first device shown in FIG. 2G inserted through afirst incision using a posterior approach to engage the vertebral body,the second device shown in FIG. 2G inserted through the first incisionusing a posterior approach to engage the vertebral body, and the thirddevice shown in FIG. 2G inserted through a second incision using alateral approach to engage the vertebral body, where at least one of thefirst and second devices are in a first plane and the third device is ina second plane that is different than the first plane;

FIG. 2I is a side view in part phantom, of a vertebral body includingthe first device shown in FIG. 2G inserted through a first incisionusing a posterior approach to engage the vertebral body, the seconddevice shown in FIG. 2G inserted through the first incision using aposterior approach to engage the vertebral body, and the third deviceshown in FIG. 2G inserted through a second incision using a lateralapproach to engage the vertebral body, where at least one of the firstand second devices are in a first plane and the third device is in asecond plane that is different than the first plane;

FIG. 2J is a top, perspective view, in part phantom, of a vertebral bodythat is accessed in the patient's middle lower back and includes a firstdevice that is inserted through a first incision using a MinimallyInvasive Lateral Interbody Fusion procedure with a posterior approach toengage the vertebral body;

FIG. 2K is a side view in part phantom, of the vertebral body shown inFIG. 2J that is accessed in the patient's middle lower back and includesthe first device shown in FIG. 2J inserted through the first incisionusing a Minimally Invasive Lateral Interbody Fusion procedure with aposterior approach to engage the vertebral body;

FIG. 2L is a top, perspective view, in part phantom, of a vertebral bodythat is accessed in the patient's middle lower back and includes a firstdevice that is inserted through a first incision using a MinimallyInvasive Lateral Interbody Fusion procedure with a posterior approach toengage the vertebral body;

FIG. 2M is a side view in part phantom, of the vertebral body shown inFIG. 2L that is accessed in the patient's middle lower back and includesthe first device shown in FIG. 2L inserted through the first incisionusing a Minimally Invasive Lateral Interbody Fusion procedure with aposterior approach to engage the vertebral body;

FIG. 3A is a top, perspective view, in part phantom, of first and secondvertebral bodies, with a first device extending through a first incisionusing a posterior approach such that the first device extends throughthe first vertebral body and into a space between the first and secondvertebral bodies, and a second device extending through a secondincision using a lateral approach to position the second device in thespace between the first and second vertebral bodies such that the firstdevice engages the second device and a tip of the first device isposterior to the second device;

FIG. 3B is a side view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3A, with the first device shown in FIG.3A extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intothe space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3A extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the first device engages thesecond device and a tip of the first device is posterior to the seconddevice;

FIG. 3C is a top view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3A, with the first device shown in FIG.3A extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intothe space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3A extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the first device engages thesecond device and a tip of the first device is posterior to the seconddevice;

FIG. 3D is a top, perspective view, in part phantom, of first and secondvertebral bodies, with a first device extending through a first incisionusing a posterior approach such that the first device extends throughthe first vertebral body and into a space between the first and secondvertebral bodies, and a second device extending through a secondincision using a lateral approach to position the second device in thespace between the first and second vertebral bodies such that a tip ofthe first device is positioned within the second device and a head ofthe first device is posterior to a facet of the first vertebral body;

FIG. 3E is a side view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3D, with the first device shown in FIG.3D extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intoa space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3D extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the tip of the first deviceis positioned within the second device and the head of the first deviceis posterior to the facet of the first vertebral body;

FIG. 3F is a top view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3D, with the first device shown in FIG.3D extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intoa space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3D extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the tip of the first deviceis positioned within the second device and the head of the first deviceis posterior to the facet of the first vertebral body;

FIG. 3G is a top, perspective view, in part phantom, of first and secondvertebral bodies, with a first device extending through a first incisionusing a posterior approach such that the first device extends throughthe first vertebral body and into a space between the first and secondvertebral bodies, and a second device extending through a secondincision using a lateral approach to position the second device in thespace between the first and second vertebral bodies such that a tip ofthe first device is positioned within the second device and a head ofthe first device is posterior to a facet of the first vertebral body,where the first device is a cannulated bone screw and the second deviceis an interbody implant;

FIG. 3H is a side view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3G, with the first device shown in FIG.3G extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intoa space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3G extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the tip of the first deviceis positioned within the second device and the head of the first deviceis posterior to the facet of the first vertebral body, where the firstdevice is a cannulated bone screw and the second device is an interbodyimplant;

FIG. 3I is a top view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3G, with the first device shown in FIG.3G extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intoa space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3G extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the tip of the first deviceis positioned within the second device and the head of the first deviceis posterior to the facet of the first vertebral body, where the firstdevice is a cannulated bone screw and the second device is an interbodyimplant;

FIG. 3J is a top, perspective view, in part phantom, of first and secondvertebral bodies, with a first device extending through a first incisionusing a posterior approach such that the first device extends throughthe first vertebral body and into a space between the first and secondvertebral bodies, and a second device extending through a secondincision using a lateral approach to position the second device in thespace between the first and second vertebral bodies such that the firstdevice engages the second device and a tip of the first device isanterior to the second device;

FIG. 3K is a side view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3J, with the first device shown in FIG.3J extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intothe space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3J extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the first device engages thesecond device and a tip of the first device is anterior to the seconddevice;

FIG. 3L is a top view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3J, with the first device shown in FIG.3J extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intothe space between the first and second vertebral bodies, and the seconddevice shown in FIG. 3J extending through a second incision using alateral approach to position the second device in the space between thefirst and second vertebral bodies such that the first device engages thesecond device and a tip of the first device is anterior to the seconddevice;

FIG. 3M is a top, perspective view, in part phantom, of first and secondvertebral bodies, with a first device extending along a first surgicalpathway using a posterior approach such that the first device extendsthrough the first vertebral body and into a space between the first andsecond vertebral bodies, a second device extending along a secondsurgical pathway using a lateral approach to position the second devicein the space between the first and second vertebral bodies such that thesecond device engages the first device, a third device extending along athird surgical pathway using a posterior approach such that the thirddevice extends through the first vertebral body and into contact withthe second device, a fourth device extending along a fourth surgicalpathway using a posterior approach such that the fourth device extendsthrough the second vertebral body and into the second device, and afifth device extending along a fifth surgical pathway using a posteriorapproach such that the fifth device extends through the second vertebralbody and into the second device;

FIG. 3N is a side view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3M, with the first device shown in FIG.3M extending along a first surgical pathway using a posterior approachsuch that the first device extends through the first vertebral body andinto a space between the first and second vertebral bodies, the seconddevice shown in FIG. 3M extending along a second surgical pathway usinga lateral approach to position the second device in the space betweenthe first and second vertebral bodies such that the second deviceengages the first device, the third device shown in FIG. 3M extendingalong a third surgical pathway using a posterior approach such that thethird device extends through the first vertebral body and into contactwith the second device, the fourth device shown in FIG. 3M extendingalong a fourth surgical pathway using a posterior approach such that thefourth device extends through the second vertebral body and into thesecond device, and the fifth device shown in FIG. 3M extending along afifth surgical pathway using a posterior approach such that the fifthdevice extends through the second vertebral body and into the seconddevice;

FIG. 3O is a top view, in part phantom, of the first and secondvertebral bodies shown in FIG. 3M, with the first device shown in FIG.3M extending along a first surgical pathway using a posterior approachsuch that the first device extends through the first vertebral body andinto a space between the first and second vertebral bodies, the seconddevice shown in FIG. 3M extending along a second surgical pathway usinga lateral approach to position the second device in the space betweenthe first and second vertebral bodies such that the second deviceengages the first device, the third device shown in FIG. 3M extendingalong a third surgical pathway using a posterior approach such that thethird device extends through the first vertebral body and into contactwith the second device, the fourth device shown in FIG. 3M extendingalong a fourth surgical pathway using a posterior approach such that thefourth device extends through the second vertebral body and into thesecond device, and the fifth device shown in FIG. 3M extending along afifth surgical pathway using a posterior approach such that the fifthdevice extends through the second vertebral body and into the seconddevice;

FIG. 3P is an enlarged top view, in part phantom, of the first andsecond vertebral bodies shown in FIG. 3M, showing the relativeorientations and position of each of the first, second, third, fourth,and fifth devices shown in FIG. 3M;

FIG. 3Q is an enlarged top, perspective view, in part phantom, of thefirst and second vertebral bodies shown in FIG. 3M, showing the relativeorientations and position of each of the first, second, third, fourth,and fifth devices shown in FIG. 3M;

FIG. 3R is an enlarged side, perspective view, in part phantom, of thefirst and second vertebral bodies shown in FIG. 3M, showing the relativeorientations and position of each of the first, second, third, fourthand fifth devices shown in FIG. 3M;

FIG. 3S is an enlarged side view, in part phantom, of the first andsecond vertebral bodies shown in FIG. 3M, showing the relativeorientations and position of each of the first, second, third, fourth,and fifth devices shown in FIG. 3M;

FIG. 4A is a top, perspective view, in part phantom, of first and secondvertebral bodies, with a first device extending through a first incisionusing a posterior approach such that the first device extends throughthe first vertebral body and into the second vertebral body, and asecond device extending through a second incision using a lateralapproach to position the second device in a space between the first andsecond vertebral bodies;

FIG. 4B is a side view, in part phantom, of the first and secondvertebral bodies shown in FIG. 4A, with the first device shown in FIG.4A extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intothe second vertebral body, and the second device shown in FIG. 4Aextending through a second incision using a lateral approach to positionthe second device in a space between the first and second vertebralbodies; and

FIG. 4C is a top view, in part phantom, of the first and secondvertebral bodies shown in FIG. 4A, with the first device shown in FIG.4A extending through a first incision using a posterior approach suchthat the first device extends through the first vertebral body and intothe second vertebral body, and the second device shown in FIG. 4Aextending through a second incision using a lateral approach to positionthe second device in a space between the first and second vertebralbodies.

DETAILED DESCRIPTION

The exemplary embodiments of the methods disclosed are discussed interms of methods for the treatment of musculoskeletal disorders and moreparticularly, in terms of methods for treating a spine. It should beunderstood that the various embodiments described herein may also beuseful for establishing multiple surgical pathways in the treatment ofother body systems or structures which may include, but are not limitedto: orthopedic, cardiac, otolaryngologic and gastrointestinal. In someembodiments, the methods for treating a spine include, for example,antero-lateral interbody fusion (ALIF), oblique lateral interbody fusion(OLIF), midline interbody fusion (MIDLIF), and/or a direct lateralinterbody fusion (DLIF).

In one embodiment, interbody implants and instruments are provided thatare each positioned through different insertion pathways simultaneouslyto access at least a portion of the patient's spine. The presentdisclosure may be understood more readily by reference to the followingdetailed description of the embodiments taken in connection with theaccompanying drawing figures, which form a part of this disclosure. Itis to be understood that this application is not limited to the specificdevices, methods, conditions or parameters described and/or shownherein, and that the terminology used herein is for the purpose ofdescribing particular embodiments by way of example only and is notintended to be limiting. Also, as used in the specification andincluding the appended claims, the singular forms “a,” “an,” and “the”include the plural, and reference to a particular numerical valueincludes at least that particular value, unless the context clearlydictates otherwise. Ranges may be expressed herein as from “about” or“approximately” one particular value and/or to “about” or“approximately” another particular value. When such a range isexpressed, another embodiment includes from the one particular valueand/or to the other particular value. Similarly, when values areexpressed as approximations, by use of the antecedent “about,” it willbe understood that the particular value forms another embodiment. It isalso understood that all spatial references, such as, for example,horizontal, vertical, top, upper, lower, bottom, left and right, are forillustrative purposes only and can be varied within the scope of thedisclosure. For example, the references “upper” and “lower” are relativeand used only in the context to the other, and are not necessarily“superior” and “inferior”.

Further, as used in the specification and including the appended claims,“treating” or “treatment” of a disease or condition refers to performinga procedure that may include administering one or more drugs to apatient (human, normal or otherwise or other mammal), employingimplantable devices, and/or employing instruments that treat thedisease, such as, for example, microdiscectomy instruments used toremove portions bulging or herniated discs and/or bone spurs, in aneffort to alleviate signs or symptoms of the disease or condition.Alleviation can occur prior to signs or symptoms of the disease orcondition appearing, as well as after their appearance. Thus, treatingor treatment includes preventing or prevention of disease or undesirablecondition (e.g., preventing the disease from occurring in a patient, whomay be predisposed to the disease but has not yet been diagnosed ashaving it). In addition, treating or treatment does not require completealleviation of signs or symptoms, does not require a cure, andspecifically includes procedures that have only a marginal effect on thepatient. Treatment can include inhibiting the disease, e.g., arrestingits development, or relieving the disease, e.g., causing regression ofthe disease. For example, treatment can include reducing acute orchronic inflammation; alleviating pain and mitigating and inducingre-growth of new ligament, bone and other tissues; as an adjunct insurgery; and/or any repair procedure. Also, as used in the specificationand including the appended claims, the term “tissue” includes softtissue, ligaments, tendons, cartilage and/or bone unless specificallyreferred to otherwise.

The following discussion includes a description of a surgical system andrelated methods of employing the surgical system in accordance with theprinciples of the present disclosure. Alternate embodiments are alsodisclosed. Reference is made in detail to the exemplary embodiments ofthe present disclosure, which are illustrated in the accompanyingfigures. Turning to FIGS. 1-4C, there are illustrated components of asurgical system, such as, for example, a spinal implant system 10.

The components of spinal implant system 10 can be fabricated frombiologically acceptable materials suitable for medical applications,including metals, synthetic polymers, ceramics and bone material and/ortheir composites, depending on the particular application and/orpreference of a medical practitioner. For example, the components ofspinal implant system 10, individually or collectively, can befabricated from materials such as stainless steel alloys, commerciallypure titanium, titanium alloys, Grade 5 titanium, superelastic titaniumalloys, cobalt-chrome alloys, stainless steel alloys, superelasticmetallic alloys (e.g., Nitinol, super elasto-plastic metals, such as GUMMETAL® manufactured by Toyota Material Incorporated of Japan), ceramicsand composites thereof such as calcium phosphate (e.g., SKELITE™manufactured by Biologix Inc.), thermoplastics such aspolyaryletherketone (PAEK) including polyetheretherketone (PEEK),polyetherketoneketone (PEKK) and polyetherketone (PEK), carbon-PEEKcomposites, PEEK-BaSO4 polymeric rubbers, polyethylene terephthalate(PET), fabric, silicone, polyurethane, silicone-polyurethane copolymers,polymeric rubbers, polyolefin rubbers, hydrogels, semi-rigid and rigidmaterials, elastomers, rubbers, thermoplastic elastomers, thermosetelastomers, elastomeric composites, rigid polymers includingpolyphenylene, polyamide, polyimide, polyetherimide, polyethylene,epoxy, bone material including autograft, allograft, xenograft ortransgenic cortical and/or corticocancellous bone, and tissue growth ordifferentiation factors, partially resorbable materials, such as, forexample, composites of metals and calcium-based ceramics, composites ofPEEK and calcium based ceramics, composites of PEEK with resorbablepolymers, totally resorbable materials, such as, for example, calciumbased ceramics such as calcium phosphate such as hydroxyapatite (HA),corraline HA, biphasic calcium phosphate, tricalcium phosphate, orfluorapatite, tri-calcium phosphate (TCP), HA-TCP, calcium sulfate, orother resorbable polymers such as polyaetide, polyglycolide,polytyrosine carbonate, polycaroplaetohe and their combinations,biocompatible ceramics, mineralized collagen, bioactive glasses, porousmetals, bone particles, bone fibers, morselized bone chips, bonemorphogenetic proteins (BMP), such as BMP-2, BMP-4, BMP-7, rhBMP-2, orrhBMP-7, demineralized bone matrix (DBM), transforming growth factors(TGF, e.g., TGF-β), osteoblast cells, growth and differentiation factor(GDF), insulin-like growth factor 1, platelet-derived growth factor,fibroblast growth factor, or any combination thereof.

Various components of spinal implant system 10 may have materialcomposites, including the above materials, to achieve various desiredcharacteristics such as strength, rigidity, elasticity, compliance,biomechanical performance, durability and radiolucency or imagingpreference. The components of spinal implant system 10, individually orcollectively, may also be fabricated from a heterogeneous material suchas a combination of two or more of the above-described materials (forexample, various PEEK interbody implants may be selectively coated withporous titanium). The components of spinal implant system 10 may bemonolithically formed, integrally connected or include fasteningelements and/or instruments, as described herein.

Spinal implant system 10 is employed, for example, with a fully opensurgical procedure, a minimally invasive procedure, includingpercutaneous techniques, and mini-open surgical techniques to deliverand introduce instrumentation and/or an implant, such as, for example,at least one interbody implant, at a surgical site within a subject bodyB of a patient, which includes, for example, a spine having vertebrae V.In some embodiments, the implant(s) can include spinal constructs, suchas, for example, pins, bone fasteners, spinal rods, connectors and/orplates.

As shown in FIG. 1A, body B includes a posterior portion P, an anteriorportion A and opposite right lateral and left lateral portions RL, LLbetween posterior and anterior portions P, A. The instrumentation and/orimplants of system 10 can be introduced into the patient using aposterior approach, an anterior approach, a right lateral approach, aleft lateral approach, or a combination thereof. The posterior approachinvolves accessing at least one of vertebrae V through the back of thepatient, such as, for example, posterior portion P. The anteriorapproach involves accessing at least one of vertebrae V through thefront of the patient, such as, for example, anterior portion A. Theright lateral approach involves accessing at least one of vertebrae Vthrough the side of the patient, such as, for example, right lateralportion RL. The left lateral approach involves accessing at least one ofvertebrae V through the side of the patient, such as, for example, leftlateral portion LL.

In some embodiments, the posterior approach involves accessing at leastone of vertebrae V via a pathway extending at an angle that isperpendicular to a coronal plane CP of body B and/or an acute anglerelative to coronal plane CP. In some embodiments, the acute angle is ina range of about −45° o to about 45° o relative to a sagittal plane SPof body B and/or up to a right angle relative to coronal plane CP in arange of about −90° to about −90° relative to a sagittal plane SP ofbody B. In some embodiments, the anterior approach involves accessing atleast one of vertebrae V via a pathway extending at an angle that isperpendicular to coronal plane CP of body B and/or an acute anglerelative to coronal plane CP. In some embodiments, the acute angle is ina range of about −45° to about 45° relative to a sagittal plane SP ofbody B and/or up to a right angle relative to sagittal plane SP in arange of about −90° to about 90° relative to a sagittal plane SP of bodyB. In some embodiments, the right and left lateral approaches eachaccess at least one of vertebrae V along a pathway extending parallel tocoronal plane CP and/or at an acute angle relative to coronal plane CP.In some embodiments, the acute angle is a range of about −45° to about45° relative to coronal plane CP of body B.

In one embodiment, shown in FIGS. 1D-1H, 1M, and 1M, a first incision I1is made in posterior portion P of a patient on to the right of asagittal plane of body B, such as, for example, a midsagittal plane SPand a second incision I2 is made in posterior portion P of the patientto the left of sagittal plane SP, as shown in FIG. 1D, for example.First incision I1 defines a first surgical pathway to vertebrae V usinga posterior approach and second incision I2 defines a second surgicalpathway to vertebrae V using a posterior approach. First and secondincisions I1, I2 are configured to provide access to at least a firstvertebral body V1 and a second vertebral body V2 of vertebrae V. A thirdincision I3, as shown in FIG. 1D, for example, is made in left lateralportion LL of the patient. Third incision I3 defines a third surgicalpathway to vertebrae V using a lateral approach to provide access to atleast first vertebral body V1 and second vertebral body V2. In someembodiments, at least one of first, second and third incisions I1, I2,I3 is created for use in a fully open surgical procedure, a minimallyinvasive procedure, including percutaneous techniques, and mini-opensurgical techniques that use a tube, such as, for example, a METRX®tube, an XTUBE® retractor or a QUADRANT™ retractor, all available fromMedtronic Spine. In some embodiments, each of portions A, P, RL, LL caninclude one or a plurality of incisions, such as, for example, theincisions discussed above. That is, there is one or a plurality ofincisions per surgical approach plane. In some embodiments, first,second and third incisions I1, I2, I3 can be anywhere in the patient'sbody where multiple entry points are necessary and/or desirable. Thevarious incisions I1, I2, I3, for example, may be sized as relativelysmall “stab” incisions for percutaneous procedures, and/or longer >30 mmincisions that may be expanded to a “mini-open” incision or full openincision where larger swaths of the bony anatomy are exposed.Furthermore, various retractors and/or dilators may be used to preventtissue migration into the working corridors initially established viaincisions I1, I2, I3. Furthermore, the incisions I1, I2, I3 in a singleprocedure may be made with substantially equal sizes or have a varietyof sizes to accommodate the various instruments, inserters and/orimplants described more fully herein. The working spaces or workingcorridors defined by a combination of instruments via the incisions maybe defined virtually by surgical navigation means as described furtherherein.

As shown in FIG. 1E, for example, a first device D1, such as, forexample, a Steinmann pin or a posted/extended screw, is inserted intofirst incision I1 such that first device D1 extends along the firstsurgical pathway using a posterior approach to engage first vertebralbody V1 to the right of sagittal plane SP percutaneously. In someembodiments, first device D1 engages a portion of first vertebral bodyV1 between the articular process of first vertebral body V1 and thetransverse process of first vertebral body V1. In some embodiments, apilot hole is made in first vertebral body V1 for first device D1, andfirst device D1 is inserted into the pilot hole such that threads on anouter surface of first device D1 engage a portion of first vertebralbody V1 that defines the pilot hole and first device D1 is rotated abouta longitudinal axis defined by first device D1 until first device D1threadingly engages first vertebral body V1. In some embodiments, firstdevice D1 is threaded into first vertebral body V1 using a driver, suchas, for example, a screw driver or an instrument I that engages aproximal end of first device D1. In some embodiments, first device D1 isthreaded into first vertebral body V1 using a surgical drill, such as,for example, a drill and/or tap included in the POWEREASE™ System soldby Medtronic. Any of the above-mentioned drivers or instruments may befitted with surgical navigation elements to establish and monitor thedevice D1 insertion trajectory intra-operatively, using a navigationand/or imaging system.

A second device D2, such as, for example, a Steinmann pin or aposted/extended screw, is inserted into second incision I2 (as shown inFIG. 1E) such that second device D2 extends along the second surgicalpathway using a posterior approach to engage first vertebral body V1 tothe left of sagittal plane SP percutaneously. In some embodiments,second device D2 engages a portion of first vertebral body V1 betweenthe articular process of first vertebral body V1 and the transverseprocess of first vertebral body V1. In some embodiments, a pilot hole ismade in first vertebral body V1 for second device D2, and second deviceD2 is inserted into the pilot hole such that threads on an outer surfaceof second device D2 engage a portion of first vertebral body V1 thatdefines the pilot hole and second device D2 is rotated about alongitudinal axis defined by second device D2 until second device D2threadingly engages first vertebral body V1.

In some embodiments, second device D2 is threaded into first vertebralbody V1 using a driver, such as, for example, a screw driver or aninstrument I that engages a proximal end of second device D2. In someembodiments, second device D2 is threaded into first vertebral body V1using a surgical drill, such as, for example, a drill and/or tapincluded in the POWEREASE™ System sold by Medtronic. In someembodiments, second device D2 is inserted into second incision I2 toengage first vertebral body V1 without moving the patient from aposition in which first device D1 is inserted into first incision I1 toengage first vertebral body V1. That is, the patient is not moved orrepositioned to insert second device D2 into second incision I2 toengage first vertebral body V1 after inserting first device D1 intofirst incision I1 to engage first vertebral body V1. In someembodiments, the patient's position is maintained between the insertionof first device D1 into first incision I1 to engage first vertebral bodyV1 and the insertion of second device D2 into second incision I2 toengage first vertebral body V1, at least in part, by a device, such as,for example, a surgical table, a surgical bed, cushions, wedges, etc. Insome embodiments, the device is a dynamic surgical table system, suchas, for example, that disclosed in U.S. Pat. No. 7,234,180, which isincorporated herein by reference, in its entirety. In some embodiments,the patient is maintained in a position such that coronal plane CP ofbody B is disposed at an angle α, such as, for example an acute anglerelative to a floor F of the operating room, as shown in FIG. 1L, forexample.

A third device D3, such as, for example, a Steinmann pin or aposted/extended screw, is inserted into second incision I2 (as shown inFIG. 1E) such that third device D3 extends along the second surgicalpathway using a posterior approach to engage second vertebral body V2 tothe left of sagittal plane SP percutaneously. In some embodiments, thirddevice D3 engages a portion of second vertebral body V2 between thearticular process of second vertebral body V2 and the transverse processof second vertebral body V2. In some embodiments, a pilot hole is madein second vertebral body V2 for third device D3, and third device D3 isinserted into the pilot hole such that threads on an outer surface ofthird device D3 engage a portion of second vertebral body V2 thatdefines the pilot hole and third device D3 is rotated about alongitudinal axis defined by third device D3 until third device D3threadingly engages second vertebral body V2.

In some embodiments, third device D3 is threaded into second vertebralbody V2 using a driver, such as, for example, a screw driver or aninstrument I that engages a proximal end of third device D3. In someembodiments, third device D3 is threaded into second vertebral body V2using a surgical drill, such as, for example, a drill and/or tapincluded in the POWEREASE™ System sold by Medtronic. In someembodiments, third device D3 is inserted into second incision I2 toengage second vertebral body V2 without moving the patient from aposition in which first and second devices D1, D2 are inserted intofirst incision I1 and second incision I2, respectively, to engage firstvertebral body V1. That is, the patient is not moved or repositioned toinsert third device D3 into second incision I2 to engage secondvertebral body V2 after inserting first and second devices D1, D2 intofirst incision I1 and second incision I2, respectively, to engage firstvertebral body V1. In some embodiments, the patient's position ismaintained between the insertion of first and second devices D1, D2 intofirst incision I1 and second incision I2, respectively, to engage firstvertebral body V1 and the insertion of third device D3 into secondincision I2 to engage second vertebral body V2, at least in part, by adevice, such as, for example, a surgical table, a surgical bed,cushions, wedges, etc. In some embodiments, the device is a dynamicsurgical table system, such as, for example, that disclosed in U.S. Pat.No. 7,234,180, which is incorporated herein by reference, in itsentirety. In some embodiments, the patient is maintained in a positionsuch that coronal plane CP of body B is disposed at an angle α, such as,for example an acute angle relative to a floor F of the operating room,as shown in FIG. 1L, for example.

A fourth device D4, such as, for example, a Steinmann pin or aposted/extended screw, is inserted into third incision I3 (as shown inFIG. 1E) such that fourth device D4 extends along the third surgicalpathway using a lateral approach to engage first vertebral body V1 tothe left of sagittal plane SP percutaneously. In some embodiments, apilot hole is made in first vertebral body V1 for fourth device D4, andfourth device D4 is inserted into the pilot hole such that threads on anouter surface of fourth device D4 engage a portion of first vertebralbody V1 that defines the pilot hole and fourth device D4 is rotatedabout a longitudinal axis defined by fourth device D4 until fourthdevice D4 threadingly engages first vertebral body V1.

In some embodiments, fourth device D4 is threaded into first vertebralbody V1 using a driver, such as, for example, a screw driver or aninstrument I that engages a proximal end of fourth device D4. In someembodiments, fourth device D4 is threaded into first vertebral body V1using a surgical drill, such as, for example, a drill and/or tapincluded in the POWEREASE™ System sold by Medtronic. In someembodiments, fourth device D4 is inserted into third incision I3 toengage first vertebral body V1 without moving the patient from aposition in which first, second and third devices D1, D2, D3 areinserted into first and second incisions I1, I2 to engage first andsecond vertebral bodies V1, V2. That is, the patient is not moved orrepositioned to insert fourth device D4 into third incision I3 to engagefirst vertebral body V1 after inserting first, second and third deviceD1, D2, D3 into first and second incisions I1, I2 to engage first andsecond vertebral bodies V1, V2. In some embodiments, the patient'sposition is maintained between the insertion of first, second and thirddevices D1, D2, D3 into first and second incisions I1, I2 to engagefirst and second vertebral bodies V1, V2, and the insertion of fourthdevice D4 into third incision I3 to engage first vertebral body V1, atleast in part, by a device, such as, for example, a surgical table, asurgical bed, cushions, wedges, etc. In some embodiments, the device isa dynamic surgical table system, such as, for example, that disclosed inU.S. Pat. No. 7,234,180, which is incorporated herein by reference, inits entirety. In some embodiments, the patient is maintained in aposition such that coronal plane CP of body B is disposed at an angle α,such as, for example an acute angle relative to a floor F of theoperating room, as shown in FIG. 1L, for example.

A fifth device D5, such as, for example, a Steinmann pin or aposted/extended screw, is inserted into third incision I3 (as shown inFIG. 1E) such that fifth device D5 extends along the third surgicalpathway using a lateral approach to engage second vertebral body V2 tothe left of sagittal plane SP percutaneously. In some embodiments, apilot hole is made in second vertebral body V2 for fifth device D5, andfifth device D5 is inserted into the pilot hole such that threads on anouter surface of fifth device D5 engage a portion of second vertebralbody V2 that defines the pilot hole and fifth device D5 is rotated abouta longitudinal axis defined by fifth device D5 until fifth device D5threadingly engages second vertebral body V2.

In some embodiments, fifth device D5 is threaded into second vertebralbody V2 using a driver, such as, for example, a screw driver or aninstrument I that engages a proximal end of fifth device D5. In someembodiments, fifth device D5 is threaded into second vertebral body V2using a surgical drill, such as, for example, a drill and/or tapincluded in the POWEREASE™ System sold by Medtronic. In someembodiments, fifth device D5 is inserted into third incision I3 toengage second vertebral body V2 without moving the patient from aposition in which first, second, third and fourth devices D1, D2, D3, D4are inserted into first, second and third incisions I1, I2, I3 to engagefirst and second vertebral bodies V1, V2. That is, the patient is notmoved or repositioned to insert fifth device D5 into third incision I3to engage second vertebral body V2 after inserting first, second, thirdand fourth devices D1, D2, D3, D4 into first, second and third incisionsI1, I2, I3 to engage first and second vertebral bodies V1, V2. In someembodiments, the patient's position is maintained between the insertionof first, second, third and fourth devices D1, D2, D3, D4 into first,second and third incisions I1, I2, I3 to engage first and secondvertebral bodies V1, V2, and the insertion of fifth device D5 into thirdincision I3 to engage second vertebral body V2, at least in part, by adevice, such as, for example, a surgical table, a surgical bed,cushions, wedges, etc. In some embodiments, the device is a dynamicsurgical table system, such as, for example, that disclosed in U.S. Pat.No. 7,234,180, which is incorporated herein by reference, in itsentirety. In some embodiments, the patient is maintained in a positionsuch that coronal plane CP of body B is disposed at an angle α, such as,for example an acute angle relative to a floor F of the operating room,as shown in FIG. 1L, for example.

A sixth device D6, such as, for example, a Steinmann pin or aposted/extended screw, is inserted into first incision I1 (as shown inFIG. 1E) such that sixth device D6 extends along the first surgicalpathway using a posterior approach to engage second vertebral body V2 tothe right of sagittal plane SP percutaneously. In some embodiments,sixth device D6 engages a portion of second vertebral body V2 betweenthe articular process of second vertebral body V2 and the transverseprocess of second vertebral body V2. In some embodiments, a pilot holeis made in second vertebral body V2 for sixth device D6, and sixthdevice D6 is inserted into the pilot hole such that threads on an outersurface of sixth device D6 engage a portion of second vertebral body V2that defines the pilot hole and sixth device D6 is rotated about alongitudinal axis defined by sixth device D6 until sixth device D6threadingly engages second vertebral body V2.

In some embodiments, sixth device D6 is threaded into second vertebralbody V2 using a driver, such as, for example, a screw driver or aninstrument I that engages a proximal end of sixth device D6. In someembodiments, sixth device D6 is threaded into second vertebral body V2using a surgical drill, such as, for example, a drill and/or tapincluded in the POWEREASE™ System sold by Medtronic. In someembodiments, sixth device D6 is inserted into first incision I1 toengage second vertebral body V2 without moving the patient from aposition in which first, second, third, fourth and fifth devices D1, D2,D3, D4, D5 are inserted into first, second and third incisions I1, I2,I3 to engage first and second vertebral bodies V1, V2. That is, thepatient is not moved or repositioned to insert sixth device D6 intofirst incision I1 to engage second vertebral body V2 after insertingfirst, second, third, fourth and fifth devices D1, D2, D3, D4, D5 intofirst, second and third incisions I1, I2, I3 to engage first and secondvertebral bodies V1, V2. In some embodiments, the patient's position ismaintained between the insertion of first, second, third, fourth andfifth devices D1, D2, D3, D4, D5 into first, second and third incisionsI1, I2, I3 to engage first and second vertebral bodies V1, V2, and theinsertion of sixth device D6 into first incision I1 to engage secondvertebral body V2, at least in part, by a device, such as, for example,a surgical table, a surgical bed, cushions, wedges, etc. In someembodiments, the device is a dynamic surgical table system, such as, forexample, that disclosed in U.S. Pat. No. 7,234,180, which isincorporated herein by reference, in its entirety. In some embodiments,the patient is maintained in a position such that coronal plane CP ofbody B is disposed at an angle α, such as, for example an acute anglerelative to a floor F of the operating room, as shown in FIG. 1L, forexample.

In some embodiments, first, second and fourth devices D1, D2, D4 aremoved relative to third, fifth and sixth devices D3, D5, D6 to move theposition of first vertebral body V1 relative to second vertebral bodyV2. In some embodiments, first, second and fourth devices D1, D2, D4 aremoved relative to third, fifth and sixth devices D3, D5, D6 to separatefirst vertebral body V1 from second vertebral body V2 in a manner thatcreates a space for a seventh device D7, such as, for example, aninterbody implant, an expandable interbody implant, a trial implant, anexpandable trial (such as the Medtronic Spine SCISSOR JACK® distractor),an inflatable implant or one or more Fernstrom balls. In someembodiments, as shown in FIG. 1M, for example, first device D1 isseparated from sixth device D6 by a first gap G1 and second device D2 isseparated from third device D3 by a second gap G2, first device D1 isdrawn toward sixth device D6 and/or sixth device D6 is drawn towardfirst device D1 to reduce the width of first gap G1, and second deviceD2 is drawn toward third device D3 and/or third device D3 is drawntoward second device D2 to reduce the width of second gap G2. Reducingthe widths of first and second gaps G1, G2 decreases separation of firstvertebral body V1 and second vertebral body V2 in portion P, and createsgreater separation between first vertebral body V1 and second vertebralbody V2 in portions A, RL, LL to facilitate insertion of seventh deviceD7.

Seventh device D7 is inserted into third incision I3 such that seventhdevice D7 extends along the third surgical pathway using a lateralapproach to position seventh device D7 in the space between firstvertebral body V1 and second vertebral body V2 percutaneously, as shownin FIG. 1G, for example. In some embodiments, seventh device D7 isinserted into third incision I3 for positioning in the space betweenfirst vertebral body V1 and second vertebral body V2 without moving thepatient from a position in which first, second, third, fourth, fifth andsixth devices D1, D2, D3, D4, D5, D6 are inserted into first, second andthird incisions I1, I2, I3 to engage first and second vertebral bodiesV1, V2. That is, the patient is not moved or repositioned to insertseventh device D7 into third incision I3 for positioning in the spacebetween first vertebral body V1 and second vertebral body V2 afterinserting first, second, third, fourth, fifth and sixth devices D1, D2,D3, D4, D5, D6 into first and second incisions I1, I2 to engage firstand second vertebral bodies V1, V2. In some embodiments, fourth andfifth devices D4, D5 are removed after device D7 is positioned in thespace between first vertebral body V1 and second vertebral body V2, asshown in FIG. 1H, for example.

In one embodiment, shown in FIG. 1O, devices D4, D5 are inserted throughthird incision I3 after device D7 is positioned in the space betweenfirst vertebral body V1 and second vertebral body V2. That is, first,second, third and sixth devices D1, D2, D3, D6 are inserted throughfirst and second incisions I1, I2 to engage first and second vertebralbodies V1, V2 in the manner discussed above. First and second devicesD1, D2 are moved relative to third and sixth devices D3, D6 to movefirst vertebral body V1 relative to second vertebral body V2 to create aspace between first vertebral body V1 and second vertebral body V2 forseventh device D7. Seventh device D7 is inserted into the space betweenfirst vertebral body V1 and second vertebral body V2 through thirdincision I3 in the manner discussed above. Fourth and fifth devices D4,D5 are inserted through third incision I3 in the manner discussed aboveuntil fourth and fifth devices D4, D5 extend through first and secondvertebral bodies V1, V2 and into seventh device D7.

In some embodiments, first, second, third and sixth devices D1, D2, D3,D6 are used as fiducial pins and/or surgical landmarks for reference innavigating or enabling robotic surgical procedures.

In one embodiment, shown in FIG. 1Q, at least one of first, second,third, fourth, fifth, sixth and seventh devices D1, D2, D3, D4, D5, D6,D7 are inserted into body B using an instrument, such as, for example,instrument N having integrated neuromonitoring and/or navigationcapabilities. In some embodiments, instrument N is used to establishand/or monitor the trajectories of at least one of first, second, third,fourth, fifth, sixth and seventh devices D1, D2, D3, D4, D5, D6, D7.That is, instrument N may be used to determine and/or select a safetrajectory in relation to the patient's anatomy for at least one offirst, second, third, fourth, fifth, sixth and seventh devices D1, D2,D3, D4, D5, D6, D7, even as that anatomy shifts in real-time and/orensure that at least one of first, second, third, fourth, fifth, sixthand seventh devices D1, D2, D3, D4, D5, D6, D7 is being inserted and/orimplanted using the selected trajectory. In some embodiments, instrumentN is part of a navigation system sold by Medtronic, such as, forexample, StealthStation® S7®, StealthStation i7™, StealthStation iNav®,AxiEM Electromagnetic Navigation System, Fusion™ ENT and/or StealthViz™Planning Station. In some embodiments, use of instrument N and/oranother instrument having integrated neuromonitoring and/or navigationcapabilities aids a medical practitioner to perform safer, more preciseprocedure, reduce procedure invasiveness and risk and/or improve patientoutcomes and recovery.

In some embodiments, imaging is used to establish and/or monitor thetrajectories of at least one of first, second, third, fourth, fifth,sixth and seventh devices D1, D2, D3, D4, D5, D6, D7 through incisionsI1, I2, I3 using the approaches discussed above. In one embodiment, animaging system, such as, for example, the O-arm Surgical Imaging Systemavailable from Medtronic is used to establish and/or monitor thetrajectories of at least one of first, second, third, fourth, fifth,sixth and seventh devices D1, D2, D3, D4, D5, D6, D7 usingintra-operative imaging. The O-arm Surgical Imaging System, among otherthings, provides fast access to real-time, multi-plane 3D images (and 2Dimages), provides full support of the unique workflow of procedures,such as, for example, spinal procedures, minimizes radiation dose forsurgical staff (by reducing X-ray exposure, for example) and providesvisualization to confirm hardware therapy placement, potentiallyeliminating revision surgeries.

In some embodiments, fourth device D4 intersects at least one of firstdevice D1 and second device D2 such that fourth device D4 extendsthrough at least one of first device D1 and second device D2. That is,at least one of first device D1 and second device D2 includes a threadedshaft configured to penetrate tissue, such as, for example, bone, whereat least one aperture extends through the threaded shaft such that theaperture(s) extend(s) transverse to a longitudinal axis defined by firstdevice D1 or second device D2. A shaft of fourth device D4 extendsthrough one of the apertures in first device D1 and/or one of theapertures in second device D2. In some embodiments, first device D1,second device D2 and fourth device D4 are similar in structure and/orfunction to the components of the cannulated and fenestrated bonefastener disclosed in U.S. patent application Ser. No. 13/446,347, whichis incorporated herein by reference, in its entirety.

In some embodiments, fifth device D5 intersects at least one of sixthdevice D6 and third device D3 such that fifth device D5 extends throughat least one of sixth device D6 and third device D3. That is, at leastone of sixth device D6 and third device D3 includes a threaded shaftconfigured to penetrate tissue, such as, for example, bone, where atleast one aperture extends through the threaded shaft such that theaperture(s) extend(s) transverse to a longitudinal axis defined by sixthdevice D6 or third device D3. A shaft of fifth device D5 extends throughone of the apertures in sixth device D6 and/or one of the apertures inthird device D3. In some embodiments, third device D3, fifth device D5and sixth device D6 are similar in structure and/or function to thecomponents of the cannulated and fenestrated bone fastener disclosed inU.S. patent application Ser. No. 13/446,347, which is incorporatedherein by reference, in its entirety.

In some embodiments, at least one of first, second, third, fourth, fifthand sixth devices D1, D2, D3, D4, D5, D6 are fixed to at least anotherone of first, second, third, fourth, fifth and sixth devices D1, D2, D3,D4, D5, D6. In some embodiments, at least one of first, second, third,fourth, fifth and sixth devices D1, D2, D3, D4, D5, D6 are fixed to asurgical bed, such as, for example, a frame of a surgical bed. In someembodiments, at least one of first, second, third, fourth, fifth andsixth devices D1, D2, D3, D4, D5, D6 is used to manipulate vertebrae Vto correct deformities while at least one of first, second, third,fourth, fifth and sixth devices D1, D2, D3, D4, D5, D6 is used todistract the space between first vertebral body V1 and second vertebralbody V2 to create a space for seventh device D7 in the manner describedabove.

In some embodiments, at least one of first, second, third, fourth, fifthand sixth devices D1, D2, D3, D4, D5, D6 is cannulated and/orfenestrated nail or tube. In some embodiments, at least one of first,second, third, fourth, fifth and sixth devices D1, D2, D3, D4, D5, D6 isa cannulated and/or fenestrated screw. In some embodiments, where atleast one of first, second, third, fourth, fifth and sixth devices D1,D2, D3, D4, D5, D6 is a screw, the thread on the screw may comprise theOSTEOGRIP® thread pattern available from Medtronic, having a varyingpitch and/or thread-count in order to optimize screw purchase in bonystructures having layers of hard cortical bone and softer cancellousbone. In some embodiments, a guide wire is inserted to guide at leastone of first, second, third, fourth, fifth and sixth devices D1, D2, D3,D4, D5, D6. That is, at least one guide wire is inserted into firstvertebral body V1 and/or second vertebral body V2. One of the guidewiresis inserted into the cannula of one of first, second, third, fourth,fifth and sixth devices D1, D2, D3, D4, D5, D6. First, second, third,fourth, fifth and sixth devices D1, D2, D3, D4, D5, D6 are then slidalong the guidewires to engage first, second, third, fourth, fifth andsixth devices D1, D2, D3, D4, D5, D6 in the manner described above.

In some embodiments, at least one of first, second, third, fourth, fifthand sixth devices D1, D2, D3, D4, D5, D6 is a cannulated screw withoutfenestrations and/or a cannulated screw having at least one lateralfenestration that is in communication with the cannula, such as, forexample, that disclosed in U.S. Pat. No. 6,565,572 and/or U.S. patentapplication Ser. No. 13/397,316, which are each incorporated herein byreference, in their entireties. In some embodiments, a material isintroduced through the cannulae and/or fenestrations of at least one offirst, second, third, fourth, fifth and sixth devices D1, D2, D3, D4,D5, D6 to deliver the material to first vertebral body V1 and/or secondvertebral body V2. In some embodiments, the material is bone cement, abone growth material, such as, for example, bone morphogenetic protein(BMP), an analgesic and/or an anti-inflammatory agent. In someembodiments, an instrument is introduced through the cannulae and/orfenestrations of at least one of first, second, third, fourth, fifth andsixth devices D1, D2, D3, D4, D5, D6 to provide navigationalcapabilities and/or stimulate bone growth. In some embodiments, theinstrument is a probe and/or electrodes.

In one embodiment, shown in FIG. 2A, a first device D10, such as, forexample, a bone screw, is positioned through a first surgical pathwayusing a posterior approach to engage a first vertebral body V1 to theright of sagittal plane SP percutaneously. In some embodiments, firstdevice D10 engages a portion of first vertebral body V1 between thearticular process of vertebral body V1 and the transverse process offirst vertebral body V1. In some embodiments, a pilot hole is made infirst vertebral body V1 for first device D10 and first device D10 isinserted into the pilot hole such that threads on the outer surface of ashaft 12 of first device D10 engage a portion of first vertebral body V1that define the pilot hole and first device D10 is rotated about alongitudinal axis L defined by shaft 12 until first device D10threadingly engages first vertebral body V1. In some embodiments, firstdevice D10 is threaded into the pilot hole and/or first vertebral bodyV1 using an instrument, such as, for example, a driver that engages atool engaging portion 14 of shaft 12. In some embodiments, first deviceD10 is threaded into first vertebral body V1 using a surgical drill,such as, for example, a drill and/or tap included in the POWEREASE™System sold by Medtronic. In some embodiments, first device D10 includesreceiver 16 that is rotatably coupled to shaft 12. Receiver 16 comprisesa pair of arms defining an implant cavity, such as, for example aU-shaped implant cavity (such as the “tulip head” of a multi-axial screw(MAS) available as part of the Medtronic CD HORIZON® SOLERA® spinalimplant system) configured for disposal of a connecting element, suchas, for example, a surgical rod. In some embodiments, first device D10is inserted into first vertebral body V1 such that longitudinal axis Lextends at an angle relative to sagittal plane SP. In some embodiments,angle β is an acute angle. In some embodiments, angle β is an anglebetween about 1 and 45 degrees. In some embodiments, shaft 12 can bevariously configured, such as, for example, smooth, ringed and/or havevarious cross sectional configurations, such as, for example, square,polygonal or round. In some embodiments, receiver 16 is fixed to shaftsuch that first device D10 is a monoaxial or uniaxial screw.

In some embodiments, first device D10 is positioned through the firstsurgical pathway using a posterior approach to engage first vertebralbody V1 to the left of sagittal plane SP percutaneously and first deviceD10 is inserted into first vertebral body V1 such that longitudinal axisL extends at an angle α relative to sagittal plane SP. In someembodiments, angle γ is an acute angle. In some embodiments, angle γ isan angle between about 1 and 45 degrees.

A second device D20 is positioned through a second surgical pathwayusing a lateral approach to engage first vertebral body V1 to the leftof sagittal plane SP percutaneously. In some embodiments, a pilot holeis made in first vertebral body V1 for second device D20, and seconddevice D20 is inserted into the pilot hole such that threads on theouter surface of a shaft 18 of second device D20 engage a portion offirst vertebral body V1 that define the pilot hole and second device D20is rotated about a longitudinal axis L1 defined by shaft 18 until seconddevice D20 threadingly engages first vertebral body V1. In someembodiments, second device D20 is threaded into the pilot hole and/orfirst vertebral body V1 using an instrument, such as, for example, adriver that engages a tool engaging portion 20 of shaft 18. In someembodiments, second device D20 is threaded into first vertebral body V1using a surgical drill, such as, for example, a drill and/or tapincluded in the POWEREASE™ System sold by Medtronic. As shown in FIG.2A, second device D20 is inserted relative to first device D10 such thatshaft 12 is spaced apart from shaft 18. In some embodiments, seconddevice D20 is inserted into first vertebral body V1 such thatlongitudinal axis L1 extends parallel to coronal plane CP. In someembodiments, axis L1 extends at an angle λ relative to coronal plane CP.In some embodiments, angle λ is an acute angle. In some embodiments,angle λ is an angle between about 1 and 45 degrees. In some embodiments,axis L1 extends at an angle δ relative to coronal plane CP. In someembodiments, angle δ is an acute angle. In some embodiments, angle δ isan angle between about 1 and 45 degrees. In some embodiments, seconddevice D20 is positioned through a second surgical pathway using alateral approach to engage first vertebral body V1 to the right ofsagittal plane SP percutaneously. In some embodiments, first device D10and second device D20 are each in the same transverse plane of body B.In some embodiments, shaft 18 can be variously configured, such as, forexample, smooth, ringed and/or have various cross sectionalconfigurations, such as, for example, square, polygonal or round.

In some embodiments, second device D20 is inserted through the secondsurgical pathway to engage first vertebral body V1 without moving thepatient from a position in which first device D10 is inserted throughthe first surgical pathway to engage first vertebral body V1. That is,the patient is not moved or repositioned to insert second device D20within body B to engage first vertebral body V1 after inserting firstdevice D10 into body B to engage first vertebral body V1. In someembodiments, the patient's position is maintained between the insertionof first device D10 through the first surgical pathway to engage firstvertebral body V1 and the insertion of second device D20 through thesecond surgical pathway to engage first vertebral body V1, at least inpart, by a device, such as, for example, a surgical table, a surgicalbed, cushions, wedges, etc. In some embodiments, the device is a dynamicsurgical table system, such as, for example, that disclosed in U.S. Pat.No. 7,234,180, which is incorporated herein by reference, in itsentirety. In some embodiments, the patient is maintained in a positionsuch that coronal plane CP of body B is disposed at an angle α, such as,for example an acute angle relative to a floor F of the operating room,as shown in FIG. 1L, for example.

In one embodiment, shown in FIG. 2B, the length of shaft 18 in FIG. 2Bis greater than the length of shaft 18 in FIG. 2A such that a distal tip13 of shaft 12 engages and/or comes into close proximity shaft 18 toincrease loading on first vertebral body V1, especially any points nearthe shafts where there is additional load imparted on the bonystructure. According to Wolff's law, for example, increasing the loadingon a bone, such as, for example a vertebra, will cause the bone toremodel itself over time to resist such increased loading. That is thebone will become stronger by, for example, increasing the thickness ofcortical bone. In some embodiments, the amount of loading on firstvertebral body V1 is increased when shaft 18 engages shaft 12 than whenshaft 18 is spaced apart from shaft 12. Thus the combinations ofimplants placed as shown in FIGS. 2A-2I may act to strengthen otherwiseweakened, structurally-compromised and/or fractured vertebrae as well ascreate a rigid and/or semi-rigid support structure within the vertebrae.

As also shown in FIG. 2B, a third device D30, such as, for example abone screw is positioned through a third surgical pathway using aposterior approach to engage first vertebral body V1 to the left ofsagittal plane SP percutaneously. In some embodiments, third device D30engages a portion of first vertebral body V1 between the articularprocess of vertebral body V1 and the transverse process of firstvertebral body V1. In some embodiments, a pilot hole is made in firstvertebral body V1 for third device D30, and third device D30 is insertedinto the pilot hole such that threads on the outer surface of a shaft 22of third device D30 engage a portion of first vertebral body V1 thatdefine the pilot hole and third device D30 is rotated about alongitudinal axis L2 defined by shaft 22 until third device D30threadingly engages first vertebral body V1. In some embodiments, thirddevice D30 is threaded into the pilot hole and/or first vertebral bodyV1 using an instrument, such as, for example, a driver that engages atool engaging portion 24 of shaft 22. In some embodiments, third deviceD30 includes receiver 26 that is rotatably coupled to shaft 22. Receiver26 comprises a pair of arms defining an implant cavity, such as, forexample a U-shaped implant cavity (such as a “tulip head” typicallyassociated with multi-axial screws in spinal implant systems) configuredfor disposal of a connecting element, such as, for example, a surgicalrod. In some embodiments, third device D30 is inserted into firstvertebral body V1 such that longitudinal axis L2 extends at an angle εrelative to sagittal plane SP. In some embodiments, angle ε is an acuteangle. In some embodiments, angle ε is an angle between about 1 and 45degrees. In some embodiments, first device D10, second device D20 andthird device D30 are each in the same transverse plane of body B. Insome embodiments, shaft 22 can be variously configured, such as, forexample, smooth, ringed and/or have various cross sectionalconfigurations, such as, for example, square, polygonal or round.

In some embodiments, third device D30 is substantially similar to seconddevice D20. In some embodiments, axis L extends at a first angle (e.g.,angle β) relative to sagittal plane SP and axis L2 extends at a secondangle (e.g., angle c) relative to sagittal plane SP, where the first andsecond angles are inverse angles. That is, the angle axis L extendsrelative to sagittal plane SP is the inverse of the angle axis L2extends relative to sagittal plane SP. For example, if axis L extends atan angle β of 30° relative to sagittal plane SP, axis L2 extends anangle ε of −30° relative to sagittal plane SP, and vice versa.

As shown in FIG. 2B, third device D30 is positioned relative to seconddevice D20 such that a distal tip 23 of shaft 22 engages shaft 18 toincrease the loading on first vertebral body V1. That is, the amount ofloading on first vertebral body V1 is increased when shaft 22 engagesshaft 18 and shaft 18 engages shaft 12 than when shaft 18 engages shaft12 without shaft 22 engaging shaft 18. According to Wolff's law, theincreased loading caused by having shafts 12, 22 each engage shaft 18causes first vertebral body V1 to become stronger by, for example,increasing the thickness of cortical bone.

In some embodiments, third device D30 is inserted through the thirdsurgical pathway to engage first vertebral body V1 without moving thepatient from a position in which first device D10 is inserted throughthe first surgical pathway to engage first vertebral body V1 and seconddevice D20 is inserted through the second surgical pathway to engagefirst vertebral body V1. That is, the patient is not moved orrepositioned to insert third device D30 within body B to engage firstvertebral body V1 after inserting first device D10 and second device D20into body B to engage first vertebral body V1. In some embodiments, thepatient's position is maintained between the insertion of first deviceD10 through the first surgical pathway to engage first vertebral bodyV1, the insertion of second device D20 through the second surgicalpathway to engage first vertebral body V1, and the insertion of thirddevice 30 through the third surgical pathway to engage first vertebralbody V1, at least in part, by a device, such as, for example, a surgicaltable, a surgical bed, cushions, wedges, etc. In some embodiments, thedevice is a dynamic surgical table system, such as, for example, thatdisclosed in U.S. Pat. No. 7,234,180, which is incorporated herein byreference, in its entirety. In some embodiments, the patient ismaintained in a position such that coronal plane CP of body B isdisposed at an angle α, such as, for example an acute angle relative toa floor F of the operating room, as shown in FIG. 1L, for example.

As shown in FIG. 2C, first device D10 is positioned through a firstsurgical pathway using a posterior approach to engage first vertebralbody V1 to the right of sagittal plane SP percutaneously. First deviceD10 engages a portion of first vertebral body V1 between the articularprocess of vertebral body V1 and the transverse process of firstvertebral body V1. First device D10 is inserted into first vertebralbody V1 such that longitudinal axis L extends at an angle β relative tosagittal plane SP. In some embodiments, angle β is an acute angle. Insome embodiments, angle β is an angle between about 1 and 45 degrees.

Second device D20 is positioned through a second surgical pathway usinga lateral approach to engage first vertebral body V1 to the left ofsagittal plane SP percutaneously. Second device D20 is inserted intofirst vertebral body V1 such that longitudinal axis L1 extends parallelto coronal plane CP. In some embodiments, axis L1 extends at an angle λrelative to coronal plane CP. In some embodiments, angle λ is an acuteangle. In some embodiments, angle λ is an angle between about 1 and 45degrees. In some embodiments, axis L1 extends at an angle δ relative tocoronal plane CP. In some embodiments, angle δ is an acute angle. Insome embodiments, angle δ is an angle between about 1 and 45 degrees. Insome embodiments, second device D20 is positioned through a secondsurgical pathway using a lateral approach to engage first vertebral bodyV1 to the right of sagittal plane SP percutaneously. In someembodiments, first device D10 and second device D20 are each in the sametransverse plane of body B. As shown in FIG. 2C, shaft 18 engages shaft12 to increase loading on first vertebral body V1.

In some embodiments, second device D20 is inserted through the secondsurgical pathway to engage first vertebral body V1 without moving thepatient from a position in which first device D10 is inserted throughthe first surgical pathway to engage first vertebral body V1. That is,the patient is not moved or repositioned to insert second device D20within body B to engage first vertebral body V1 after inserting firstdevice D10 into body B to engage first vertebral body V1. In someembodiments, the patient's position is maintained between the insertionof first device D10 through the first surgical pathway to engage firstvertebral body V1 and the insertion of second device D20 through thesecond surgical pathway to engage first vertebral body V1, at least inpart, by a device, such as, for example, a surgical table, a surgicalbed, cushions, wedges, etc. In some embodiments, the device is a dynamicsurgical table system, such as, for example, that disclosed in U.S. Pat.No. 7,234,180, which is incorporated herein by reference, in itsentirety. In some embodiments, the patient is maintained in a positionsuch that coronal plane CP of body B is disposed at an angle α, such as,for example an acute angle relative to a floor F of the operating room,as shown in FIG. 1L, for example.

In one embodiment, shown in FIG. 2D, first device D10 is a cannulatedbone screw that is positioned through a first surgical pathway using aposterior approach to engage a first vertebral body V1 to the right ofsagittal plane SP percutaneously, as described above with reference toFIG. 2A and/or FIG. 2B. Second device D20 is a cannulated bone screwthat is positioned through a second surgical pathway using a lateralapproach to engage first vertebral body V1 to the left of sagittal planeSP percutaneously, as described above with reference to FIG. 2A and/orFIG. 2B. As shown in FIG. 2D, second device D20 is inserted relative tofirst device D10 such that shaft 12 is spaced apart from shaft 18. Insome embodiments, second device D20 is inserted into first vertebralbody V1 such that longitudinal axis L1 extends parallel to coronal planeCP. In some embodiments, axis L1 extends at an angle λ relative tocoronal plane CP. In some embodiments, angle λ is an acute angle. Insome embodiments, angle λ is an angle between about 1 and 45 degrees. Insome embodiments, axis L1 extends at an angle δ relative to coronalplane CP. In some embodiments, angle δ is an acute angle. In someembodiments, angle δ is an angle between about 1 and 45 degrees. In someembodiments, second device D20 is positioned through a second surgicalpathway using a lateral approach to engage first vertebral body V1 tothe right of sagittal plane SP percutaneously. In some embodiments,first device D10 and second device D20 are each in the same transverseplane of body B.

In some embodiments, second device D20 is inserted through the secondsurgical pathway to engage first vertebral body V1 without moving thepatient from a position in which first device D10 is inserted throughthe first surgical pathway to engage first vertebral body V1. That is,the patient is not moved or repositioned to insert second device D20within body B to engage first vertebral body V1 after inserting firstdevice D10 into body B to engage first vertebral body V1. In someembodiments, the patient's position is maintained between the insertionof first device D10 through the first surgical pathway to engage firstvertebral body V1 and the insertion of second device D20 through thesecond surgical pathway to engage first vertebral body V1, at least inpart, by a device, such as, for example, a surgical table, a surgicalbed, cushions, wedges, etc. In some embodiments, the device is a dynamicsurgical table system, such as, for example, that disclosed in U.S. Pat.No. 7,234,180, which is incorporated herein by reference, in itsentirety. In some embodiments, the patient is maintained in a positionsuch that coronal plane CP of body B is disposed at an angle α, such as,for example an acute angle relative to a floor F of the operating room,as shown in FIG. 1L, for example.

In some embodiments, a guide wire is inserted to guide at least one offirst and second devices D10, D20. That is, at least one guide wire isinserted into first vertebral body V1. One of the guidewires is insertedinto the cannula of one of first and second devices D10, D20. First andsecond devices D10, D20 are then slid along the guidewires to engagefirst and second devices D10, D20 with first vertebral body V1 in themanner described above.

In some embodiments, a material is introduced through the cannulae of atleast one of first and second devices D10, D20 to deliver the materialto first vertebral body V1. In some embodiments, the material is bonecement, a bone growth material, such as, for example, bone morphogeneticprotein (BMP), an analgesic and/or an anti-inflammatory agent. In someembodiments, an instrument is introduced through the cannulae of atleast one of first and second devices D10, D20 to provide navigationalcapabilities and/or stimulate bone growth. In some embodiments, theinstrument is a probe and/or electrodes.

In one embodiment, shown in FIG. 2E, the length of shaft 12 in FIG. 2Eis greater than the length of shaft 12 in FIG. 2A such that a distal tip19 of shaft 18 engages shaft 12 to increase loading on first vertebralbody V1 and tip 13 is spaced apart from shaft 18. In one embodiment,first device D10 is a pedicle screw and second device D20 is a lateralscrew having a maximum length that is less than that of first deviceD10.

In one embodiment, shown in FIG. 2F, the length of shaft 18 in FIG. 2Fis greater than the length of shaft 18 in FIG. 2A such that tip 13 ofshaft 12 engages shaft 18 to increase loading on first vertebral body V1and tip 19 is spaced apart from shaft 12. In one embodiment, firstdevice D10 is a pedicle screw and second device D20 is a lateral screwhaving a maximum length that is greater than that of first device D10.

In one embodiment, shown in FIGS. 2G-2I, first device D10 is positionedthrough the first surgical pathway using a posterior approach to engagefirst vertebral body V1 to the right of sagittal plane SPpercutaneously. First device D10 engages a portion of first vertebralbody V1 between the articular process of vertebral body V1 and thetransverse process of first vertebral body V1 such that longitudinalaxis L extends at an acute angle relative to coronal plane CP and shaft12 extends in a cranial direction through first vertebral body V1.Second device D20 is positioned through the second surgical pathwayusing a lateral approach to engage first vertebral body V1 to the leftof sagittal plane SP percutaneously. Second device D20 is inserted intofirst vertebral body V1 such that longitudinal axis L1 extends parallelto coronal plane CP and/or a transverse plane TP of body B. Shaft 12and/or tip 13 are positioned more toward a cranial end of body B than isshaft 18 such that shaft 12 is spaced apart from shaft 18. Third deviceD30 is positioned through the third surgical pathway using a posteriorapproach to engage first vertebral body V1 to the left of sagittal planeSP percutaneously. Third device D30 engages a portion of first vertebralbody V1 between the articular process of vertebral body V1 and thetransverse process of first vertebral body V1 such that longitudinalaxis L2 extends at an acute angle relative to coronal plane CP and shaft22 extends in a caudal direction through first vertebral body V1. Shaft22 and/or tip 23 are positioned more toward a caudal end of body B thanis shaft 12 such that shaft 22 is spaced apart from shafts 12, 18.

In one embodiment, shown in FIGS. 2J and 2K, first device D10 is used inperforming a midline interbody fusion (MIDLIF) and is positioned throughthe first surgical pathway using a posterior approach to engage firstvertebral body V1 to the left of sagittal plane SP percutaneously and/orvia a “mini-open” hybrid technique using a smaller near-midline incisionas described in Medtronic's MAST MIDLF® technique. First device D10engages a portion of first vertebral body V1 between the articularprocess of vertebral body V1 and the transverse process of firstvertebral body V1 such that longitudinal axis L extends at an angle β(FIG. 2K) relative to coronal plane CP. In some embodiments, angle β(FIG. 2K) is an obtuse angle. In some embodiments, angle β (FIG. 2K) isan angle between about 91 and 120 degrees.

In one embodiment, shown in FIGS. 2L and 2M, first device D10 is used inperforming midline interbody fusion (MIDLIF) and is positioned throughthe first surgical pathway using a posterior approach to engage firstvertebral body V1 to the left of sagittal plane SP percutaneously. Firstdevice D10 engages a portion of first vertebral body V1 between thearticular process of vertebral body V1 and the transverse process offirst vertebral body V1 such that longitudinal axis L extends at anangle β (FIG. 2M) relative to coronal plane CP. In some embodiments,angle β (FIG. 2M) is an acute angle. In some embodiments, angle β (FIG.2M) is an angle between about 1 and 75 degrees.

In any of the embodiments shown in FIGS. 2A-2M, at least one of first,second and third devices D10, D20, D30 may be inserted into body B usingan instrument, such as, for example, an instrument having integratedneuromonitoring and/or navigation capabilities. In some embodiments, theinstrument having integrated neuromonitoring and/or navigationcapabilities is used to establish and/or monitor the trajectories of atleast one of first, second and third devices D10, D20, D30. That is, theinstrument having integrated neuromonitoring and/or navigationcapabilities may be used to determine and/or select a safe trajectory inrelation to the patient's anatomy for at least one first, second andthird devices D10, D20, D30, even as that anatomy shifts in real-timeand/or ensure that at least one of first, second and third devices D10,D20, D30 is being inserted and/or implanted using the selectedtrajectory. In some embodiments, the instrument having integratedneuromonitoring and/or navigation capabilities is part of a navigationsystem sold by Medtronic, such as, for example, StealthStation® S7®,StealthStation i7™ StealthStation iNav®, AxiEM ElectromagneticNavigation System, Fusion™ ENT and/or StealthViz™ Planning Station. Insome embodiments, the instrument having integrated neuromonitoringand/or navigation capabilities aids a medical practitioner to performsafer, more precise procedure, reduce procedure invasiveness and riskand/or improve patient outcomes and recovery.

In any of the embodiments shown in FIGS. 2A-2M, imaging may be used toestablish and/or monitor the trajectories of at least one of first,second and third devices D10, D20, D30 through incisions using theapproaches discussed above. In one embodiment, an imaging system, suchas, for example, the O-arm Surgical Imaging System available fromMedtronic is used to establish and/or monitor the trajectories of atleast one of first, second and third devices D10, D20, D30 usingintra-operative imaging. The O-arm Surgical Imaging System, among otherthings, provides fast access to real-time, multi-plane 3D images (and 2Dimages), provides full support of the unique workflow of procedures,such as, for example, spinal procedures, minimizes radiation dose forsurgical staff (by reducing X-ray exposure, for example) and providesvisualization to confirm hardware therapy placement, potentiallyeliminating revision surgeries.

In any of the embodiments shown in FIGS. 2A-2M, at least one of first,second and third devices D10, D20, D30 may be cannulated. In someembodiments, a guide wire is inserted to guide at least one of first,second and third devices D10, D20, D30 into position relative tovertebrae V in the manner discussed above. That is, at least one guidewire is inserted into first vertebral body V1 and/or second vertebralbody V2. One of the guidewires is inserted into the cannula of one offirst, second and third devices D10, D20, D30. First, second and thirddevices D10, D20, D30 are then slid along the guidewires to engagefirst, second and third devices D10, D20, D30 with vertebrae V in themanner described above.

In any of the embodiments shown in FIGS. 2A-2M, at least one of first,second and third devices D10, D20, D30 is a cannulated screw withoutfenestrations and/or a cannulated screw having at least one lateralfenestration that is in communication with the cannula. In someembodiments, a material is introduced through the cannulae and/orfenestrations of at least one of first, second and third devices D10,D20, D30 to deliver the material to first vertebral body V1 and/orsecond vertebral body V2. In some embodiments, the material is bonecement, a bone growth material, such as, for example, bone morphogeneticprotein (BMP), an analgesic and/or an anti-inflammatory agent. In someembodiments, an instrument is introduced through the cannulae and/orfenestrations of at least one of first, second and third devices D10,D20, D30 to provide navigational capabilities and/or stimulate bonegrowth. In some embodiments, the instrument is a probe and/orelectrodes.

In one embodiment, shown in FIGS. 3A-3C, a first device D100, such as,for example, a bone screw, is positioned through a first surgicalpathway using a posterior approach to engage a first vertebral body V1of vertebrae V to the left of sagittal plane SP percutaneously. In someembodiments, first device D100 engages a portion of first vertebral bodyV1 between the articular process of vertebral body V1 and the transverseprocess of first vertebral body V1. In some embodiments, a pilot hole ismade in first vertebral body V1 for first device D100 and first deviceD100 is inserted into the pilot hole such that threads on the outersurface of a shaft 120 of first device D100 engage a portion of firstvertebral body V1 that define the pilot hole and first device D100 isrotated about a longitudinal axis L10 defined by shaft 120 until firstdevice D100 threadingly engages first vertebral body V1. In someembodiments, first device D100 is threaded into the pilot hole and/orfirst vertebral body V1 using an instrument, such as, for example, adriver that engages a tool engaging portion 140 of shaft 120. In someembodiments, first device D100 is threaded into first vertebral body V1using a surgical drill, such as, for example, a drill and/or tapincluded in the POWEREASE™ System sold by Medtronic. In someembodiments, first device D100 is inserted into first vertebral body V1such that longitudinal axis L10 extends at an angle β1 relative tosagittal plane SP. In some embodiments, angle β1 is an acute angle. Insome embodiments, angle β1 is an angle between about 1 and 45 degrees.In some embodiments, first device D100 is inserted into first vertebralbody V1 such that longitudinal axis L10 extends at an angle X1 relativeto coronal plane CP. In some embodiments, angle X1 is an acute angle. Insome embodiments, angle X1 is an angle between about 1 and 45 degrees.In some embodiments, first device D100 is inserted into first vertebralbody V1 such that a tip 121 of shaft 120 is positioned in a spacebetween first vertebral body V1 and second vertebral body V2. In someembodiments, shaft 120 can be variously configured, such as, forexample, smooth, ringed and/or have various cross sectionalconfigurations, such as, for example, square, polygonal or round.

In some embodiments, first device D100 is positioned through the firstsurgical pathway using a posterior approach to engage first vertebralbody V1 to the right of sagittal plane SP percutaneously and firstdevice D100 is inserted into first vertebral body V1 such thatlongitudinal axis L10 extends at an angle γ1 relative to sagittal planeSP. In some embodiments, angle γ1 is an acute angle. In someembodiments, angle γ1 is an angle between about 1 and 45 degrees.

A second device D200, such as, for example, an interbody implant, ispositioned through a second surgical pathway using a lateral approachand is positioned in the space between first vertebral body V1 andsecond vertebral body V2 of vertebrae V percutaneously such that tip 121is posterior to second device D200. Second device D200 is positioned inthe space between first vertebral body V1 and second vertebral body V2such that second device D200 is spaced apart from first device D100. Insome embodiments, second device D200 is inserted in the space betweenfirst vertebral body V1 and second vertebral body V2 before first deviceD100 is inserted into first vertebral body V1. In some embodiments,first vertebral body V1 and second vertebral body V2 are distractedrelative to one another to increase the space between first vertebralbody V1 and second vertebral body V2 for insertion of second deviceD200. In some embodiments, second device D200 is an interbody implant, atrial implant, a SCISSOR JACK® implant, an inflatable implant or one ormore Fernstrom balls.

In some embodiments, second device D200 is inserted through the secondsurgical pathway for positioning in the space between first vertebralbody V1 and second vertebral body V2 without moving the patient from aposition in which first device D100 is inserted through the firstsurgical pathway to engage first vertebral body V1. That is, the patientis not moved or repositioned to insert second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2 after inserting first device D100 into body B toengage first vertebral body V1. Likewise, in embodiments, where seconddevice D200 is inserted before first device D100, the patient is notmoved or repositioned to insert first device D100 into body B to engagefirst vertebral body V1 after inserting second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2.

In some embodiments, the patient's position is maintained between theinsertion of first device D100 through the first surgical pathway toengage first vertebral body V1 and the insertion of second device D200through the second surgical pathway for positioning in the space betweenfirst vertebral body V1 and second vertebral body V2, at least in part,by a device, such as, for example, a surgical table, a surgical bed,cushions, wedges, etc. In some embodiments, the device is a dynamicsurgical table system, such as, for example, that disclosed in U.S. Pat.No. 7,234,180, which is incorporated herein by reference, in itsentirety. In some embodiments, the patient is maintained in a positionsuch that coronal plane CP of body B is disposed at an angle α, such as,for example an acute angle relative to a floor F of the operating room,as shown in FIG. 1L, for example.

In one embodiment, shown in FIGS. 3D-3F, first device D100 is positionedthrough a first surgical pathway using a posterior approach to engage afirst vertebral body V1 of vertebrae V to the left of sagittal plane SPpercutaneously. In some embodiments, first device D100 engages a portionof first vertebral body V1 between the articular process of vertebralbody V1 and the transverse process of first vertebral body V1 such thata head 122 of first device D100 is posterior to a facet of firstvertebral body V1. In some embodiments, first device D100 is insertedinto first vertebral body V1 such that longitudinal axis L10 extends atan angle β2 relative to sagittal plane SP. In some embodiments, angle β2is an acute angle. In some embodiments, angle β2 is an angle betweenabout 1 and 45 degrees. In some embodiments, first device D100 isinserted into first vertebral body V1 such that longitudinal axis L10extends at an angle X2 relative to coronal plane CP.

In some embodiments, angle X2 is an acute angle. In some embodiments,angle X2 is an angle between about 1 and 45 degrees. In someembodiments, first device D100 is positioned through the first surgicalpathway using a posterior approach to engage first vertebral body V1 tothe right of sagittal plane SP percutaneously and first device D100 isinserted into first vertebral body V1 such that longitudinal axis L10extends at an angle γ2 relative to sagittal plane SP. In someembodiments, angle γ2 is an acute angle. In some embodiments, angle γ2is an angle between about 1 and 45 degrees.

Second device D200 is positioned through a second surgical pathway usinga lateral approach and is positioned in the space between firstvertebral body V1 and second vertebral body V2 of vertebrae Vpercutaneously such that a bone engaging surface 201 of second deviceD200 engages first vertebral body V1 and a bone engaging surface 202 ofsecond device D200 opposite bone engaging surface 201 engages secondvertebral body V2. Second device is positioned such that tip 121 extendsthrough an opening 203 in second device D200 that extends through andbetween bone engaging surfaces 201, 202. In some embodiments, seconddevice D200 is inserted in the space between first vertebral body V1 andsecond vertebral body V2 before first device D100 is inserted into firstvertebral body V1. In some embodiments, first vertebral body V1 andsecond vertebral body V2 are distracted relative to one another toincrease the space between first vertebral body V1 and second vertebralbody V2 for insertion of second device D200.

In some embodiments, second device D200 is inserted through the secondsurgical pathway for positioning in the space between first vertebralbody V1 and second vertebral body V2 without moving the patient from aposition in which first device D100 is inserted through the firstsurgical pathway to engage first vertebral body V1. That is, the patientis not moved or repositioned to insert second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2 after inserting first device D100 into body B toengage first vertebral body V1. Likewise, in embodiments, where seconddevice D200 is inserted before first device D100, the patient is notmoved or repositioned to insert first device D100 into body B to engagefirst vertebral body V1 after inserting second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2. In some embodiments, the patient's position ismaintained between the insertion of first device D100 through the firstsurgical pathway to engage first vertebral body V1 and the insertion ofsecond device D200 through the second surgical pathway for positioningin the space between first vertebral body V1 and second vertebral bodyV2, at least in part, by a device, such as, for example, a surgicaltable, a surgical bed, cushions, wedges, etc. In some embodiments, thedevice is a dynamic surgical table system, such as, for example, thatdisclosed in U.S. Pat. No. 7,234,180, which is incorporated herein byreference, in its entirety. In some embodiments, the patient ismaintained in a position such that coronal plane CP of body B isdisposed at an angle α, such as, for example an acute angle relative toa floor F of the operating room, as shown in FIG. 1L, for example.

In one embodiment, shown in FIGS. 3G-3I, shaft 120 is cannulated andincludes an opening a distal end thereof. First device D100 ispositioned through a first surgical pathway using a posterior approachto engage a first vertebral body V1 of vertebrae V to the left ofsagittal plane SP percutaneously. In some embodiments, first device D100engages a portion of first vertebral body V1 between the articularprocess of vertebral body V1 and the transverse process of firstvertebral body V1 such that head 122 is posterior to a facet of firstvertebral body V1. In some embodiments, first device D100 is insertedinto first vertebral body V1 such that longitudinal axis L10 extends atan angle β3 relative to sagittal plane SP. In some embodiments, angle β3is an acute angle. In some embodiments, angle β3 is an angle betweenabout 1 and 45 degrees. In some embodiments, first device D100 isinserted into first vertebral body V1 such that longitudinal axis L10extends at an angle X3 relative to coronal plane CP. In someembodiments, angle X3 is an acute angle.

In some embodiments, angle X3 is an angle between about 1 and 45degrees. In some embodiments, first device D100 is positioned throughthe first surgical pathway using a posterior approach to engage firstvertebral body V1 to the right of sagittal plane SP percutaneously andfirst device D100 is inserted into first vertebral body V1 such thatlongitudinal axis L10 extends at an angle γ3 relative to sagittal planeSP. In some embodiments, angle γ3 is an acute angle. In someembodiments, angle γ3 is an angle between about 1 and 45 degrees.

Second device D200 is positioned through a second surgical pathway usinga lateral approach and is positioned in the space between firstvertebral body V1 and second vertebral body V2 of vertebrae Vpercutaneously such that bone engaging surface 201 engages firstvertebral body V1 and bone engaging surface 202 engages second vertebralbody V2. Second device is positioned such that tip 121 extends throughopening 203. In some embodiments, second device D200 is inserted in thespace between first vertebral body V1 and second vertebral body V2before first device D100 is inserted into first vertebral body V1. Insome embodiments, first vertebral body V1 and second vertebral body V2are distracted relative to one another to increase the space betweenfirst vertebral body V1 and second vertebral body V2 for insertion ofsecond device D200.

In some embodiments, second device D200 is inserted through the secondsurgical pathway for positioning in the space between first vertebralbody V1 and second vertebral body V2 without moving the patient from aposition in which first device D100 is inserted through the firstsurgical pathway to engage first vertebral body V1. That is, the patientis not moved or repositioned to insert second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2 after inserting first device D100 into body B toengage first vertebral body V1. Likewise, in embodiments, where seconddevice D200 is inserted before first device D100, the patient is notmoved or repositioned to insert first device D100 into body B to engagefirst vertebral body V1 after inserting second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2. In some embodiments, the patient's position ismaintained between the insertion of first device D100 through the firstsurgical pathway to engage first vertebral body V1 and the insertion ofsecond device D200 through the second surgical pathway for positioningin the space between first vertebral body V1 and second vertebral bodyV2, at least in part, by a device, such as, for example, a surgicaltable, a surgical bed, cushions, wedges, etc. In some embodiments, thedevice is a dynamic surgical table system, such as, for example, thatdisclosed in U.S. Pat. No. 7,234,180, which is incorporated herein byreference, in its entirety. In some embodiments, the patient ismaintained in a position such that coronal plane CP of body B isdisposed at an angle α, such as, for example an acute angle relative toa floor F of the operating room, as shown in FIG. 1L, for example.

In some embodiments, a guide wire is inserted to guide first device D100into position. That is, a guide wire is inserted into first vertebralbody V1. The guidewire is inserted into the cannula of first deviceD100. First device D100 is then slid along the guidewire to engage firstdevice D100 with first vertebral body V1 in the manner described above.

In some embodiments, a material is introduced through the cannula offirst device D100 to deliver the material into opening 203 and/or thespace between first vertebral body V1 and second vertebral body V2. Insome embodiments, the material is bone cement, a bone growth material,such as, for example, bone morphogenetic protein (BMP), an analgesicand/or an anti-inflammatory agent. In some embodiments, an instrument isintroduced through the cannula of first device D100 to providenavigational capabilities and/or stimulate bone growth. In someembodiments, the instrument is a probe and/or electrodes.

In one embodiment, shown in FIGS. 3J-3L, first device D100 is positionedthrough a first surgical pathway using a posterior approach to engagefirst vertebral body V1 to the left of sagittal plane SP percutaneously.In some embodiments, first device D100 engages a portion of firstvertebral body V1 between the articular process of vertebral body V1 andthe transverse process of first vertebral body V1. In some embodiments,first device D100 is inserted into first vertebral body V1 such that tip121 is positioned in the space between first vertebral body V1 andsecond vertebral body V2. In some embodiments, first device D100 isinserted into first vertebral body V1 such that tip 121 is positioned infirst vertebral body V1 without extending into the space between firstvertebral body V1 and second vertebral body V2. In some embodiments,first device D100 is inserted into first vertebral body V1 such thatlongitudinal axis L10 extends at an angle β4 relative to sagittal planeSP. In some embodiments, angle β4 is an acute angle. In someembodiments, angle β4 is an angle between about 1 and 45 degrees. Insome embodiments, first device D100 is inserted into first vertebralbody V1 such that longitudinal axis L10 extends at an angle X4 relativeto coronal plane CP. In some embodiments, angle X4 is an acute angle. Insome embodiments, angle X4 is an angle between about 1 and 45 degrees.

In some embodiments, first device D100 is positioned through the firstsurgical pathway using a posterior approach to engage first vertebralbody V1 to the right of sagittal plane SP percutaneously and firstdevice D100 is inserted into first vertebral body V1 such thatlongitudinal axis L10 extends at an angle γ4 relative to sagittal planeSP. In some embodiments, angle γ4 is an acute angle. In someembodiments, angle γ4 is an angle between about 1 and 45 degrees.

Second device D200 is positioned through a second surgical pathway usinga lateral approach and is positioned in the space between firstvertebral body V1 and second vertebral body V2 of vertebrae Vpercutaneously such that tip 121 is anterior to second device D200.Second device D200 is positioned in the space between first vertebralbody V1 and second vertebral body V2 such that second device D200 isspaced apart from first device D100. In some embodiments, second deviceD200 is inserted in the space between first vertebral body V1 and secondvertebral body V2 before first device D100 is inserted into firstvertebral body V1. In some embodiments, first vertebral body V1 andsecond vertebral body V2 are distracted relative to one another toincrease the space between first vertebral body V1 and second vertebralbody V2 for insertion of second device D200.

In some embodiments, second device D200 is inserted through the secondsurgical pathway for positioning in the space between first vertebralbody V1 and second vertebral body V2 without moving the patient from aposition in which first device D100 is inserted through the firstsurgical pathway to engage first vertebral body V1. That is, the patientis not moved or repositioned to insert second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2 after inserting first device D100 into body B toengage first vertebral body V1. Likewise, in embodiments, where seconddevice D200 is inserted before first device D100, the patient is notmoved or repositioned to insert first device D100 into body B to engagefirst vertebral body V1 after inserting second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2. In some embodiments, the patient's position ismaintained between the insertion of first device D100 through the firstsurgical pathway to engage first vertebral body V1 and the insertion ofsecond device D200 through the second surgical pathway for positioningin the space between first vertebral body V1 and second vertebral bodyV2, at least in part, by a device, such as, for example, a surgicaltable, a surgical bed, cushions, wedges, etc. In some embodiments, thedevice is a dynamic surgical table system, such as, for example, thatdisclosed in U.S. Pat. No. 7,234,180, which is incorporated herein byreference, in its entirety. In some embodiments, the patient ismaintained in a position such that coronal plane CP of body B isdisposed at an angle α, such as, for example an acute angle relative toa floor F of the operating room, as shown in FIG. 1L, for example.

In one embodiment, shown in FIGS. 3M-3S, first device D100 is positionedthrough a first surgical pathway using a posterior approach to engage afirst vertebral body V1 of vertebrae V to the left of sagittal plane SPpercutaneously. In some embodiments, first device D100 engages a portionof first vertebral body V1 between the articular process of vertebralbody V1 and the transverse process of first vertebral body V1. In someembodiments, first device D100 is inserted into first vertebral body V1such that tip 121 is positioned in the space between first vertebralbody V1 and second vertebral body V2. In some embodiments, first deviceD100 is inserted into first vertebral body V1 such that tip 121 isoriented in a caudal direction. In some embodiments, first device D100is inserted into first vertebral body V1 such that longitudinal axis L10extends at an angle β5 relative to sagittal plane SP. In someembodiments, angle β5 is an acute angle. In some embodiments, angle β5is an angle between about 1 and 45 degrees. In some embodiments, firstdevice D100 is inserted into first vertebral body V1 such thatlongitudinal axis L10 extends at an angle X5 relative to coronal planeCP. In some embodiments, angle X5 is an acute angle. In someembodiments, angle X5 is an angle between about 1 and 45 degrees.

Second device D200 is positioned through a second surgical pathway usinga lateral approach and is positioned in the space between firstvertebral body V1 and second vertebral body V2 of vertebrae Vpercutaneously such that surface 201 engages first vertebral body V1,surface 202 engages second vertebral body V2 and tip 121 is posterior tosecond device D200. In some embodiments, second device D200 ispositioned in the space between first vertebral body V1 and secondvertebral body V2 such that tip 121 engages second device D200. In someembodiments, second device D200 is positioned in the space between firstvertebral body V1 and second vertebral body V2 such that second deviceD200 is spaced apart from first device D100. In some embodiments, seconddevice D200 is inserted in the space between first vertebral body V1 andsecond vertebral body V2 before first device D100 is inserted into firstvertebral body V1. In some embodiments, first vertebral body V1 andsecond vertebral body V2 are distracted relative to one another toincrease the space between first vertebral body V1 and second vertebralbody V2 for insertion of second device D200.

In some embodiments, second device D200 is inserted through the secondsurgical pathway for positioning in the space between first vertebralbody V1 and second vertebral body V2 without moving the patient from aposition in which first device D100 is inserted through the firstsurgical pathway to engage first vertebral body V1. That is, the patientis not moved or repositioned to insert second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2 after inserting first device D100 into body B toengage first vertebral body V1. Likewise, in embodiments, where seconddevice D200 is inserted before first device D100, the patient is notmoved or repositioned to insert first device D100 into body B to engagefirst vertebral body V1 after inserting second device D200 within body Bfor positioning in the space between first vertebral body V1 and secondvertebral body V2. In some embodiments, the patient's position ismaintained between the insertion of first device D100 through the firstsurgical pathway to engage first vertebral body V1 and the insertion ofsecond device D200 through the second surgical pathway for positioningin the space between first vertebral body V1 and second vertebral bodyV2, at least in part, by a device, such as, for example, a surgicaltable, a surgical bed, cushions, wedges, etc. In some embodiments, thedevice is a dynamic surgical table system, such as, for example, thatdisclosed in U.S. Pat. No. 7,234,180, which is incorporated herein byreference, in its entirety. In some embodiments, the patient ismaintained in a position such that coronal plane CP of body B isdisposed at an angle α, such as, for example an acute angle relative toa floor F of the operating room, as shown in FIG. 1L, for example.

A third device D101, such as, for example, a bone screw similar to firstdevice D100 is positioned through a third surgical pathway using aposterior approach such that a shaft 120A of third device D101 extendsthrough first vertebral body V1. In some embodiments, third device D101extends through first vertebral body V1 such that a tip 121A of thirddevice D101 extends in a caudal direction and engages surface 201. Insome embodiments, third device D101 extends through first vertebral bodyV1 such that tip 121A is anterior to tip 121. In some embodiments, thirddevice D101 extends through first vertebral body V1 such that tip 121Aextends in a caudal direction and is positioned in opening 203. In someembodiments, a pilot hole is made in first vertebral body V1 for thirddevice D101 and third device D101 is inserted into the pilot hole suchthat threads on the outer surface of a shaft 120A of third device D101engage a portion of first vertebral body V1 that define the pilot holeand third device D101 is rotated about a longitudinal axis L1OA definedby shaft 120A until third device D101 threadingly engages firstvertebral body V1. In some embodiments, third device D101 is threadedinto the pilot hole and/or first vertebral body V1 using an instrument,such as, for example, a driver that engages a tool engaging portion 140Aof shaft 120A. In some embodiments, third device D101 is threaded intofirst vertebral body V1 using a surgical drill, such as, for example, adrill and/or tap included in the POWER EASE™ System sold by Medtronic.In some embodiments, third device D101 is inserted into first vertebralbody V1 such that longitudinal axis L1OA extends at an angle β6 relativeto sagittal plane SP. In some embodiments, angle β6 is an acute angle.In some embodiments, angle β6 is an angle between about 1 and 45degrees. In some embodiments, third device D101 is inserted into firstvertebral body V1 such that longitudinal axis L1OA extends at an angleX6 relative to coronal plane CP. In some embodiments, angle X6 is anacute angle. In some embodiments, angle X6 is an angle between about 1and 45 degrees.

In some embodiments, third device D101 is inserted into first vertebralbody V1 before first device D100 is inserted into first vertebral bodyV1. In some embodiments, third device D101 is inserted into firstvertebral body V1 after first device D100 is inserted into firstvertebral body V1. In some embodiments, third device D101 is insertedinto first vertebral body V1 without moving the patient from a positionin which second device D200 is inserted into the space between firstvertebral body V1 and second vertebral body V2 and/or first device D100is inserted into first vertebral body V1. That is, the patient is notmoved or repositioned to insert third device D101 into first vertebralbody V1 such that tip 121A engages second device D200 and/or ispositioned within opening 203 after second device D200 is insertedwithin body B in the space between first vertebral body V1 and secondvertebral body V2 and/or first device D100 is inserted into firstvertebral body V1 such that tip 121 engages second device D200. In someembodiments, the patient's position is maintained between the insertionof third device D101 into first vertebral body V1 and the insertion ofsecond device D200 into the space between first vertebral body V1 andsecond vertebral body V2 and/or the insertion of first device D100 intofirst vertebral body V1, at least in part, by a device, such as, forexample, a surgical table, a surgical bed, cushions, wedges, etc. Insome embodiments, the device is a dynamic surgical table system, suchas, for example, that disclosed in U.S. Pat. No. 7,234,180, which isincorporated herein by reference, in its entirety. In some embodiments,the patient is maintained in a position such that coronal plane CP ofbody B is disposed at an angle α, such as, for example an acute anglerelative to a floor F of the operating room, as shown in FIG. 1L, forexample.

A fourth device D102, such as, for example, a bone screw similar tofirst device D100 and third device D101 is positioned through a fourthsurgical pathway using a posterior approach such that a shaft 120B offourth device D102 extends through second vertebral body V2. In someembodiments, fourth device D102 extends through second vertebral body V2such that a tip 121B of fourth device D102 extends in a cranialdirection and is positioned in opening 203. In some embodiments, fourthdevice D102 extends through second vertebral body V2 such that tip 121Bis anterior to tip 121 and posterior to tip 121A. In some embodiments, apilot hole is made in second vertebral body V2 for fourth device D102and fourth device D102 is inserted into the pilot hole such that threadson the outer surface of a shaft 120B of fourth device D102 engage aportion of second vertebral body V2 that define the pilot hole andfourth device D102 is rotated about a longitudinal axis L10B defined byshaft 120B until fourth device D102 threadingly engages second vertebralbody V2. In some embodiments, fourth device D102 is threaded into thepilot hole and/or second vertebral body V2 using an instrument, such as,for example, a driver that engages a tool engaging portion 140B of shaft120B. In some embodiments, fourth device D102 is threaded into secondvertebral body V2 using a surgical drill, such as, for example, a drilland/or tap included in the POWEREASE™ System sold by Medtronic. In someembodiments, fourth device D102 is inserted into second vertebral bodyV2 such that longitudinal axis L10B extends at an angle β 7 relative tosagittal plane SP. In some embodiments, angle β 7 is an acute angle. Insome embodiments, angle β 7 is an angle between about 1 and 45 degrees.In some embodiments, fourth device D102 is inserted into secondvertebral body V2 such that longitudinal axis L10B extends at an angleX7 relative to coronal plane CP. In some embodiments, angle X7 is anacute angle. In some embodiments, angle X7 is an angle between about 1and 45 degrees.

In some embodiments, fourth device D102 is inserted into secondvertebral body V2 before first device D100 is inserted into firstvertebral body V1 and/or third device D101 is inserted into firstvertebral body V1. In some embodiments, fourth device D102 is insertedinto second vertebral body V2 after first device D100 is inserted intofirst vertebral body V1 and/or third device D101 is inserted into firstvertebral body V1. In some embodiments, first device D100 is insertedinto first vertebral body V1, third device D101 is inserted into firstvertebral body V1 and/or fourth device D102 is inserted into secondvertebral body V2 without moving the patient from a position in whichsecond device D200 is inserted into the space between first vertebralbody V1 and second vertebral body V2. That is, the patient is not movedor repositioned to insert fourth device D102 into second vertebral bodyV2, first device D100 in first vertebral body V1 and/or third deviceD101 in first vertebral body V1 after second device D200 is insertedwithin body B in the space between first vertebral body V1 and secondvertebral body V2. In some embodiments, the patient's position ismaintained between the insertion of first device D100 into firstvertebral body V1, the insertion of third device D101 into firstvertebral body V1, the insertion of fourth device D102 into secondvertebral body V2 and/or the insertion of second device D200 into thespace between first vertebral body V1 and second vertebral body V2, atleast in part, by a device, such as, for example, a surgical table, asurgical bed, cushions, wedges, etc. In some embodiments, the device isa dynamic surgical table system, such as, for example, that disclosed inU.S. Pat. No. 7,234,180, which is incorporated herein by reference, inits entirety. In some embodiments, the patient is maintained in aposition such that coronal plane CP of body B is disposed at an angle α,such as, for example an acute angle relative to a floor F of theoperating room, as shown in FIG. 1L, for example.

A fifth device D103, such as, for example, a bone screw similar to firstdevice D100, third device D101 and fourth device D102 is positionedthrough a fifth surgical pathway using a posterior approach such that ashaft 120C of fifth device D103 extends through second vertebral bodyV2. In some embodiments, fifth device D103 extends through secondvertebral body V2 such that a tip 121C of fifth device D103 extends in acranial direction and engages surface 202. In some embodiments, fifthdevice D103 extends through second vertebral body V2 such that tip 121Cis anterior to tips 121, 121B and posterior to tip 121A. In someembodiments, a pilot hole is made in second vertebral body V2 for fifthdevice D103 and fifth device D103 is inserted into the pilot hole suchthat threads on the outer surface of a shaft 120C of fifth device D103engage a portion of second vertebral body V2 that define the pilot holeand fifth device D103 is rotated about a longitudinal axis L1OC definedby shaft 120C until fifth device D103 threadingly engages secondvertebral body V2. In some embodiments, fifth device D103 is threadedinto the pilot hole and/or second vertebral body V2 using an instrument,such as, for example, a driver that engages a tool engaging portion 140Cof shaft 120C. In some embodiments, fifth device D103 is threaded intosecond vertebral body V2 using a surgical drill, such as, for example, adrill and/or tap included in the POWEREASE™ System sold by Medtronic. Insome embodiments, fifth device D103 is inserted into second vertebralbody V2 such that longitudinal axis L1OC extends at an angle β 8relative to sagittal plane SP. In some embodiments, angle β 8 is anacute angle. In some embodiments, angle β 8 is an angle between about 1and 45 degrees. In some embodiments, fifth device D103 is inserted intosecond vertebral body V2 such that longitudinal axis L1OC extends at anangle X8 relative to coronal plane CP. In some embodiments, angle X8 isan acute angle. In some embodiments, angle X8 is an angle between about1 and 45 degrees.

In some embodiments, fifth device D103 is inserted into second vertebralbody V2 before first device D100 is inserted into first vertebral bodyV1, third device D101 is inserted into first vertebral body V1 and/orfourth device D102 is inserted into second vertebral body. In someembodiments, fourth device D102 is inserted into second vertebral bodyV2 after first device D100 is inserted into first vertebral body V1,third device D101 is inserted into first vertebral body V1 and/or fourthdevice D102 is inserted into second vertebral body. In some embodiments,first device D100 is inserted into first vertebral body V1, third deviceD101 is inserted into first vertebral body V1, fourth device D102 isinserted into second vertebral body V2 and/or fifth device D103 isinserted into second vertebral body V2 without moving the patient from aposition in which second device D200 is inserted into the space betweenfirst vertebral body V1 and second vertebral body V2. That is, thepatient is not moved or repositioned to insert fifth device D103 intosecond vertebral body V2, first device D100 in first vertebral body V1,third device D101 in first vertebral body V1 and/or fourth device D102in second vertebral body V2 after second device D200 is inserted withinbody B in the space between first vertebral body V1 and second vertebralbody V2. In some embodiments, the patient's position is maintainedbetween the insertion of first device D100 into first vertebral body V1,the insertion of third device D101 into first vertebral body V1, theinsertion of fourth device D102 into second vertebral body V2, theinsertion of fifth device D103 into second vertebral body V2 and/or theinsertion of second device D200 into the space between first vertebralbody V1 and second vertebral body V2, at least in part, by a device,such as, for example, a surgical table, a surgical bed, cushions,wedges, etc. In some embodiments, the device is a dynamic surgical tablesystem, such as, for example, that disclosed in U.S. Pat. No. 7,234,180,which is incorporated herein by reference, in its entirety. In someembodiments, the patient is maintained in a position such that coronalplane CP of body B is disposed at an angle α, such as, for example anacute angle relative to a floor F of the operating room, as shown inFIG. 1L, for example.

In any of the embodiments shown in FIGS. 3A-3S, at least one of first,second, third, fourth and fifth devices D100, D200, D101, D102, D103 maybe inserted into body B using an instrument, such as, for example, aninstrument having integrated neuromonitoring and/or navigationcapabilities. In some embodiments, the instrument having integratedneuromonitoring and/or navigation capabilities is used to establishand/or monitor the trajectories of at least one of first, second, third,fourth and fifth devices D100, D200, D101, D102, D103. That is, theinstrument having integrated neuromonitoring and/or navigationcapabilities may be used to determine and/or select a safe trajectory inrelation to the patient's anatomy for at least one first, second, third,fourth and fifth devices D100, D200, D101, D102, D103, even as thatanatomy shifts in real-time and/or ensure that at least one of first,second, third, fourth and fifth devices D100, D200, D101, D102, D103 isbeing inserted and/or implanted using the selected trajectory. In someembodiments, the instrument having integrated neuromonitoring and/ornavigation capabilities is part of a navigation system sold byMedtronic, such as, for example, StealthStation® S7®, StealthStation i7™StealthStation iNav®, AxiEM Electromagnetic Navigation System, Fusion™ENT and/or StealthViz™ Planning Station. In some embodiments, theinstrument having integrated neuromonitoring and/or navigationcapabilities aids a medical practitioner to perform safer, more preciseprocedure, reduce procedure invasiveness and risk and/or improve patientoutcomes and recovery.

In any of the embodiments shown in FIGS. 3A-3S, imaging may be used toestablish and/or monitor the trajectories of at least one of first,second, third, fourth and fifth devices D100, D200, D101, D102, D103through incisions using the approaches discussed above. In oneembodiment, an imaging system, such as, for example, the O-arm SurgicalImaging System available from Medtronic is used to establish and/ormonitor the trajectories of at least one of first, second, third, fourthand fifth devices D100, D200, D101, D102, D103 using intra-operativeimaging. The O-arm Surgical Imaging System, among other things, providesfast access to real-time, multi-plane 3D images (and 2D images),provides full support of the unique workflow of procedures, such as, forexample, spinal procedures, minimizes radiation dose for surgical staff(by reducing X-ray exposure, for example) and provides visualization toconfirm hardware therapy placement, potentially eliminating revisionsurgeries.

In any of the embodiments shown in FIGS. 3A-3S, at least one of first,third, fourth and fifth devices D100, D101, D10, D103 may be cannulated.In some embodiments, a guide wire is inserted to guide at least one offirst, third, fourth and fifth devices D100, D101, D10, D103 intoposition relative to vertebrae V in the manner discussed above. That is,at least one guide wire is inserted into first vertebral body V1 and/orsecond vertebral body V2. One of the guidewires is inserted into thecannula of one of first, third, fourth and fifth devices D100, D101,D10, D103. First, third, fourth and fifth devices D100, D101, D10, D103are then slid along the guidewires to engage first, second and thirddevices D10, D20, D30 with vertebrae V in the manner described above.

In any of the embodiments shown in FIGS. 3A-3S, at least one of first,third, fourth and fifth devices D100, D101, D10, D103 is a cannulatedscrew without fenestrations and/or a cannulated screw having at leastone lateral fenestration that is in communication with the cannula. Insome embodiments, a material is introduced through the cannulae and/orfenestrations of at least one of first, third, fourth and fifth devicesD100, D101, D10, D103 to deliver the material within second device D200,such as, for example, within opening 203 or to deliver the material tofirst vertebral body V1 and/or second vertebral body V2. In someembodiments, the material is bone cement, a bone growth material, suchas, for example, bone morphogenetic protein (BMP), an analgesic and/oran anti-inflammatory agent. In some embodiments, an instrument isintroduced through the cannulae and/or fenestrations of at least one offirst, third, fourth and fifth devices D100, D101, D10, D103 to providenavigational capabilities and/or stimulate bone growth. In someembodiments, the instrument is a probe and/or electrodes.

In one embodiment, shown in FIGS. 4A-4C, a first device D1000, such as,for example, a compression screw, is positioned through a first surgicalpathway using a posterior approach to engage a first vertebral body V1and a second vertebral body V2 of vertebrae V to the left of sagittalplane SP percutaneously. In some embodiments, first device D1000 engagesa portion of first vertebral body V1 between the articular process ofvertebral body V1 and the transverse process of first vertebral body V1and extends into a body of second vertebral body V2. In someembodiments, a shaft 1200 of first device D1000 includes an unthreadedportion 1201 connected to a head 1202 of first device D1000 and athreaded portion 1203 is connected to unthreaded portion 1201. Threadedportion 1203 defines a tip 1210 of first device D1000. In someembodiments, unthreaded portion 1201 extends through first vertebralbody V1 and across a space between first vertebral body V1 and secondvertebral body V2 such that threaded portion 1203 extends into secondvertebral body V2. In some embodiments, first device D1000 includes awasher 1205 that shaft 1200 extends through such that washer 1205 isslidable along shaft 1200. Washer 1205 engages first vertebral body V1as shaft 1200 is inserted through first vertebral body V1 and intosecond vertebral body V2. In some embodiments, further rotation of firstdevice D1000 about axis L100 causes washer 1205 to engage firstvertebral body V1 in a manner that draws first vertebral body V1 towardsecond vertebral body V2. That is, the distance between first vertebralbody V1 and second vertebral body V2 decreases.

In some embodiments, a pilot hole is made in first vertebral body V1and/or second vertebral body V2 for first device D1000 and first deviceD1000 is inserted into the pilot hole in first vertebral body V1 suchthat threads on the outer surface of threaded portion 1203 engage aportion of first vertebral body V1 that defines the pilot hole in firstvertebral body V1. First device D1000 is rotated about longitudinal axisL100 until unthreaded portion 1201 extends through first vertebral bodyV1 and space between first vertebral body V1 and second vertebral bodyV2 and the threads of threaded portion 1203 engage a portion of secondvertebral body V2 that defines the pilot hole in second vertebral bodyV2. In some embodiments, first device D1000 is threaded into the pilothole(s) and/or first vertebral body V1 and second vertebral body V2using an instrument, such as, for example, a driver that engages a toolengaging portion 1204 of head 1202. In some embodiments, first deviceD1000 is threaded into first vertebral body V1 and second vertebral bodyV2 using a surgical drill, such as, for example, a drill included in thePOWEREASE™ System sold by Medtronic.

In some embodiments, first device D1000 is inserted into first vertebralbody V1 and second vertebral body V2 such that longitudinal axis L100extends at an angle β9 relative to sagittal plane SP. In someembodiments, angle β9 is an acute angle. In some embodiments, angle β9is an angle between about 1 and 45 degrees. In some embodiments, firstdevice D1000 is inserted into first vertebral body V1 and secondvertebral body V2 such that longitudinal axis L100 extends at an angleX9 relative to coronal plane CP. In some embodiments, angle X9 is anacute angle. In some embodiments, angle X9 is an angle between about 1and 45 degrees. In some embodiments, shaft 1200 can be variouslyconfigured, such as, for example, smooth, ringed and/or have variouscross sectional configurations, such as, for example, square, polygonalor round.

In some embodiments, first device D1000 is positioned through the firstsurgical pathway using a posterior approach to extend through firstvertebral body V1 to the right of sagittal plane SP percutaneously andfirst device D1000 is inserted into first vertebral body V1 such thatlongitudinal axis L100 extends at an angle γ9 relative to sagittal planeSP. In some embodiments, angle γ9 is an acute angle. In someembodiments, angle γ9 is an angle between about 1 and 45 degrees.

A second device D2000, such as, for example, an interbody implant, ispositioned through a second surgical pathway using a lateral approachand is positioned in the space between first vertebral body V1 andsecond vertebral body V2 of vertebrae V percutaneously such that seconddevice D2000 is spaced apart from first device D1000. In someembodiments, second device D2000 is inserted in the space between firstvertebral body V1 and second vertebral body V2 before first device D1000is inserted into first vertebral body V1. In some embodiments, firstvertebral body V1 and second vertebral body V2 are distracted relativeto one another to increase the space between first vertebral body V1 andsecond vertebral body V2 for insertion of second device D2000. In someembodiments, second device D2000 is an interbody implant, a trialimplant, a SCISSOR JACK® implant, an inflatable implant or one or moreFernstrom balls.

In some embodiments, second device D2000 is inserted through the secondsurgical pathway for positioning in the space between first vertebralbody V1 and second vertebral body V2 without moving the patient from aposition in which first device D1000 is inserted through the firstsurgical pathway to extend through first vertebral body V1 and engagesecond vertebral body V2. That is, the patient is not moved orrepositioned to insert second device D2000 within body B for positioningin the space between first vertebral body V1 and second vertebral bodyV2 after inserting first device D1000 into body B to extend throughfirst vertebral body V1 and engage second vertebral body V2. Likewise,in embodiments, where second device D2000 is inserted before firstdevice D1000, the patient is not moved or repositioned to insert firstdevice D1000 into body B to extend through first vertebral body V1 andengage second vertebral body V2 after inserting second device D2000within body B for positioning in the space between first vertebral bodyV1 and second vertebral body V2. In some embodiments, the patient'sposition is maintained between the insertion of first device D1000through the first surgical pathway to extend through first vertebralbody V1 and engage second vertebral body V2 and the insertion of seconddevice D2000 through the second surgical pathway for positioning in thespace between first vertebral body V1 and second vertebral body V2, atleast in part, by a device, such as, for example, a surgical table, asurgical bed, cushions, wedges, etc. In some embodiments, the device isa dynamic surgical table system, such as, for example, that disclosed inU.S. Pat. No. 7,234,180, which is incorporated herein by reference, inits entirety. In some embodiments, the patient is maintained in aposition such that coronal plane CP of body B is disposed at an angle α,such as, for example an acute angle relative to a floor F of theoperating room, as shown in FIG. 1L, for example.

In some embodiments, at least one of first and second devices D1000,D2000 may be inserted into body B using an instrument, such as, forexample, an instrument having integrated neuromonitoring and/ornavigation capabilities. In some embodiments, the instrument havingintegrated neuromonitoring and/or navigation capabilities is used toestablish and/or monitor the trajectories of at least one of first andsecond devices D1000, D2000. That is, the instrument having integratedneuromonitoring and/or navigation capabilities may be used to determineand/or select a safe trajectory in relation to the patient's anatomy forat least one first and second devices D1000, D2000, even as that anatomyshifts in real-time and/or ensure that at least one of first and seconddevices D1000, D2000 is being inserted and/or implanted using theselected trajectory. In some embodiments, the instrument havingintegrated neuromonitoring and/or navigation capabilities is part of anavigation system sold by Medtronic, such as, for example,StealthStation® S7®, StealthStation i7™ StealthStation iNav®, AxiEMElectromagnetic Navigation System, Fusion™ ENT and/or StealthViz™Planning Station. In some embodiments, the instrument having integratedneuromonitoring and/or navigation capabilities aids a medicalpractitioner to perform safer, more precise procedure, reduce procedureinvasiveness and risk and/or improve patient outcomes and recovery.

In some embodiments, imaging may be used to establish and/or monitor thetrajectories of at least one of first and second devices D1000, D2000through incisions using the approaches discussed above. In oneembodiment, an imaging system, such as, for example, the O-arm SurgicalImaging System available from Medtronic is used to establish and/ormonitor the trajectories of at least one of first and second devicesD1000, D2000 using intra-operative imaging. The O-arm Surgical ImagingSystem, among other things, provides fast access to real-time,multi-plane 3D images (and 2D images), provides full support of theunique workflow of procedures, such as, for example, spinal procedures,minimizes radiation dose for surgical staff (by reducing X-ray exposure,for example) and provides visualization to confirm hardware therapyplacement, potentially eliminating revision surgeries.

In some embodiments, first device D1000 may be cannulated. In someembodiments, a guide wire is inserted to guide first device D1000 intoposition relative to vertebrae V in the manner discussed above. That is,a guide wire is inserted into first vertebral body V1 and/or secondvertebral body V2. The guidewire is inserted into the cannula of firstdevice D1000. First device D1000 is then slid along the guidewire toengage first device D1000 with vertebrae V in the manner describedabove.

In some embodiments, first device D1000 is a cannulated screw withoutfenestrations and/or a cannulated screw having at least one lateralfenestration that is in communication with the cannula. In someembodiments, a material is introduced through the cannula and/orfenestrations of first device D1000 to deliver the material withinsecond device D2000, such as, for example, an opening of second deviceD2000 or to deliver the material to first vertebral body V1 and/orsecond vertebral body V2. In some embodiments, the material is bonecement, a bone growth material, such as, for example, bone morphogeneticprotein (BMP), an analgesic and/or an anti-inflammatory agent. In someembodiments, an instrument is introduced through the cannula and/orfenestrations of first device D1000 to provide navigational capabilitiesand/or stimulate bone growth. In some embodiments, the instrument is aprobe and/or electrodes.

Upon completion of a procedure, as described herein, the surgicalinstruments, assemblies and non-implanted components of system 10 areremoved and the incision(s) are closed. One or more of the components ofsystem 10 can be made of radiolucent materials such as polymers.Radiopaque markers may be included for identification under x-ray,fluoroscopy, CT or other imaging techniques. In some embodiments, theuse of surgical navigation, microsurgical and image guided technologies,as described herein, may be employed to access, view and repair spinaldeterioration or damage, with the aid of system 10. In some embodiments,system 10 may include implants and/or spinal constructs, which mayinclude one or a plurality of plates, rods, connectors and/or bonefasteners for use with a single vertebral level or a plurality ofvertebral levels.

Although the procedures described above were shown and described withthe procedure occurring in or adjacent vertebrae V, it is envisionedthat present disclosure may also be used in other areas of body B, suchas, for example, vertebrae V, the patient's sacrum S, the patient'siliac bone IB, or any combination of the above. It is contemplated thatthe present disclosure may be used in any area of body B where multipleentry points are necessary.

In one embodiment, system 10 includes an agent, which may be disposed,packed, coated or layered within, on or about the components and/orsurfaces of system 10. In some embodiments, the agent may include bonegrowth promoting material, such as, for example, bone graft allograft,xenograft, autograft, bone paste, bone chips, Skelite®, and/or BMP toenhance fixation of the components and/or surfaces of system 10 withvertebrae. In some embodiments, the agent may include one or a pluralityof therapeutic agents and/or pharmacological agents for release,including sustained release, to treat, for example, pain, inflammationand degeneration. In such embodiments, titanium coatings may be appliedvia a variety of methods, including but not limited to plasma spraycoating and/or mechanical attachment of titanium plates to form aPEEK/Titanium implant.

The various embodiments described herein may be used to enable a methodfor surgically treating a spine in a patient. Referring generally toFIG. 1E the method may comprise inserting a first device (D1, forexample) through an opening I1 using a first approach; and inserting asecond device (the interbody implant 07, for example) through anotheropening I3 using another approach while the first device D1 is insertedthrough the opening I1, and where the approaches afforded by openings 1Iand I3 are different. As described herein, these approaches may compriseone or more of the following: posterior, left lateral, right lateral,anterior, oblique, and posterior midline. Oblique approaches mayinclude, but are not limited to use of the OLIF25™, OLIF51™ and OLIF41™approaches and instrumentation available from Medtronic Spine. Posteriormidline approaches may include, but are not limited to the use of theMIDLF® approach and instrumentation available from Medtronic Spine.

Referring generally to FIGS. 1E and 1L, the various methods describedherein may also further comprise positioning the patient such that theopenings (I1 and I3, for example) are accessible simultaneously. Forexample, the patient may be positioned at an angle α relative to a floorF of the operating room such that the various instruments D1-D7 (whereinD7 comprises an interbody implant, trial or inserter as shown generallyin FIG. 1E) are accessibly simultaneously to the various surgicalpersonnel in the operating room. Thus, a surgeon or assistant maymanipulate instruments (D1-D6, for example), independently or in concertto manipulate one or more vertebral bodies relative to one another whileinserting the interbody implant D7. Furthermore, instruments D1-D6 maybe used to distract and/or widen an interbody disc space to aid in discspace preparation, ligament release (such as cutting or partial cuttingof the anterior longitudinal ligament (ALL)), or distraction whileinserting an interbody implant D7 (as shown in FIG. 1E). Selectivepositioning of the patient as shown generally in FIGS. 1E and 1L mayalso allow for the creation of new surgical “working planes” alongand/or near a border of the traditional posterior and anterior quadrantwith the right and left lateral quadrants of the patient (see FIG. 1A)to facilitate a number of oblique approaches (including but not limitedto the OLIF25™, OLIF41™ and OLIF51™ procedures developed by MedtronicSpine).

Referring generally to FIGS. 1B and 1E, in some method embodiments, theopening (see I1, FIG. 1E, for example) may extend through a coronalplane CP of a body of the patient (see FIG. 1B). That is, the surgicalpathway established through opening I1 (and/or I2 as shown in FIG. 1D)may extend through and intersect the coronal plane CP. Furthermore, theopening (see I3, FIG. 1E, for example) may extend through a sagittalplane SP of a body of the patient (see FIG. 1B). That is, the surgicalpathway established through opening I3 may extend through and intersectthe sagittal plane SP.

In other embodiments, the opening I1 (and/or I2 as shown in FIG. 1D) mayextend obliquely relative to the sagittal plane SP such that the openingI1 (and/or I2) extends through and/or intersects both the coronal planeCP and the sagittal plane SP of the body of the patient. In some suchembodiments, the opening I3 (see FIG. 1E) may extend through and/orintersect the sagittal plane SP (see FIG. 1B) of the body of thepatient.

According to various method embodiments described herein, the opening I1(and/or I2 as shown in FIG. 1D) may extend at a range of angles relativeto a coronal plane CP (see FIG. 1B) of a body of the patient. Forexample, the opening I1 (and/or I2) may extend at an angle of about 90degrees to about −90 degrees relative to the coronal plane CP. In otherembodiments, the opening I1 (and/or I2) may extend at an angle of about45 degrees to about −45 degrees relative to the coronal plane CP. Theopening (see I3, FIG. 1E, for example) may also extend at a range ofangles relative to a sagittal plane SP (see FIG. 1B) of a body of thepatient. For example, the opening I3 may extend at an angle of about 90degrees to about −90 degrees relative to a sagittal plane SP (see FIG.1B). In other embodiments, the opening I3 may extend at an angle ofabout 45 degrees to about −45 degrees relative to a sagittal plane SP.

Referring again generally to FIG. 1E, in some embodiments, inserting thefirst device D1 comprises positioning the first device D1 (which mayinclude, but is not limited to a Steinmann pin or bone screw withextender) such that the first device D1 engages a first vertebral bodyV1. In some such embodiments, the method further comprises moving atleast one of the first and second devices (D1 and D2, for example)relative to the first vertebral body V1 to adjust a position of thefirst vertebral body V1 relative to a second vertebral body V2. Forexample, a surgeon might manipulate vertebral body V1 to better distractthe disc space between V1 and V2 while having the opportunity tosimultaneously prepare the disc space via the opening I3 and/or tosimultaneously insert an interbody implant (see D7, FIGS. 1E-1G, forexample) via the opening I3.

In some method embodiments as shown generally in FIG. 1E, the firstdevice may comprise a first manipulation instrument D1 and a secondmanipulation instrument D6. In such embodiments, inserting the firstdevice may comprise: (1) inserting the first manipulation instrumentthrough the opening I1 such that the first manipulation instrument D1engages a first vertebral body V1 and (2) inserting the secondmanipulation instrument D6 through the opening I1 such that the secondmanipulation instrument D6 engages a second vertebral body V2. Themethod may further comprise manipulating the first and secondmanipulation instruments D1, D6 to move the first and second vertebralbodies V1, V2 relative to one another. For example, a surgeon mayutilize instruments D1, D6 (which may comprise a variety of temporaryand/or permanent implants including, but not limited to Steinmann pinsand bone screws with break-off extensions) to manipulate vertebralbodies V1 and V2 to distract the disc space. In some embodiments, asurgeon could also correct deformities using the instruments D1, D6(using a form of vertebral column manipulation VCM) to rotate and/orde-rotate vertebral bodies V1 and V2, relative to one another.Furthermore, the various compression screw embodiments (see FIGS. 4A-4C,for example) and multi-vertebral level embodiments (see FIGS. 3A-3S, forexample) may be used to create single Functional Spinal Units (FSUs) bytying or linking multiple vertebral levels together for fixation and/ormanipulation. Thus, the various devices D1, D6 for example, describedherein may be used to manipulate an entire FSU relative to another FSU.Furthermore, the various embodiments described herein may be used forlarger-scale VCM maneuvers, where a portion of the thoracic spine ismanipulated about the axis extending generally along the spinal columnrelative to the cervical or lumbar spine (and vice-versa). Theconstruction of large scale FSUs using the methods described herein mayenable and/or facilitate such maneuvers.

Referring again to FIGS. 1E-1G, in some embodiments, the second deviceD7 may comprise a spinal implant (including but not limited to aninterbody implant such as the CLYDESDALE® implant available fromMedtronic). In such embodiments, the method may further compriseinserting the second device comprises inserting the spinal implant D7between the first and second vertebral bodies V1, V2. In otherembodiments, the second device may comprise a variety of surgicalinstruments that may be preferable inserted via the incision I3 whilemanipulation of the vertebral bodies V1, V2 is accomplished via theincision(s) (see I1, I2, FIG. 1E, for example). The second device maycomprise instruments that may include, but are not limited to:discectomy devices, disc preparation instruments, shavers, curettes,ronqeurs, Kerrison punches, trials, distractors, cylindrical pivots orfulcrum devices, expandable distractors (such as the Medtronic SCISSORJACK®), inserters. Any of the various permutations of the first andsecond devices (D1-D7) may also be inserted with the aid of surgicalnavigation technology as described further herein and as shown generallywith respect to navigated instrument N (see FIG. 1Q).

Now referring generally to FIG. 2D, in some embodiments, the first andsecond devices inserted via two openings I1, I3 (see FIG. 1E) maycomprise two bone screws having shafts 12, 18. The bone screws havingshafts 12, 18 may both be inserted into a single vertebral body V1 sothat the screws having shafts 12, 18 interact and/or come into closeproximity so as to apply stresses and/or compressive force to theinterior of the vertebral body V1 to encourage bone growth in accordancewith Wolff's law. In some embodiments, a threaded shaft of the firstbone screw 12 engages a threaded shaft of the second bone screw havingshaft 18. At least one of the bone screws having shafts 12, 18 may alsobe cannulated and/or fenestrated such that the screws having shafts 12,18 may be used to convey materials, instruments, and/or electrodes tothe interior of the vertebral body V1. For example cannulated bonescrews (see FIG. 2D, for example) may be used to convey bone growthmaterials, bone cements, bone paste, and/or analgesics to the interiorof the vertebral bodies V1, V2. In other embodiments, the cannulatedbone screws having shafts 12, 18 may also be used to introduce astimulation electrode through the cannulation and into the vertebralbody V1 or V2 (or any other bony structure treated using the variousprocedures described herein). The stimulation electrode may comprise aprobe for neural integrity monitoring (NIM) or a stimulation electrodeused to encourage bone growth in the interior of the vertebral body.

It should also be noted that any of the first and second devices D1, D2,D3, D4, D5, D6 and/or D7 as shown generally in FIGS. 1E-1G may beinserted percutaneously via one or more “stab” incisions. For example,while devices D1 and D6 are shown being inserted through a singleopening I1 in FIG. 1E, any one of the devices D1-D7 may be introducedinto a discrete incision or opening along a selected surgical approach.

A method for surgically treating a spine in a patient is also disclosed,comprising performing a first surgical procedure with the patient in asurgical position (such as the insertion of devices D1, D2, D3, D6 in anangulated patient position shown in FIG. 14 and performing a secondsurgical procedure (such as the insertion of lateral devices D4, D5)without moving the patient from the surgical position. The first andsecond surgical procedures may be selected from a group consisting of:discectomy, laminotomy, laminectomy, direct decompression, indirectdecompression, cutting an anterior longitudinal ligament, implantinsertion, trial insertion, distraction of vertebrae to ease implantinsertion, distraction of vertebrae to facilitate disc removal,distraction of vertebrae to facilitate visualization and creation of afulcrum. In some such embodiments, the first surgical procedure isdifferent than the second surgical procedure. For example, the firstsurgical procedure may comprise distraction of the vertebral bodies V1and V2 using devices D1 and D6, respectively, while the second surgicalprocedure may comprise inserting an interbody implant D7 (see FIG. 1K,for example).

It will be understood that various modifications and/or combinations maybe made to the embodiments disclosed herein. Therefore, the abovedescription should not be construed as limiting, but merely asexemplification of the various embodiments. Those skilled in the artwill envision other modifications within the scope and spirit of theclaims appended hereto.

I claim:
 1. A method for surgically treating the spine of a patient, themethod comprising: positioning a patient on a surgical table; providinga first opening into a posterior portion of the patient; providing asecond opening into a lateral portion of the patient; inserting a firstmanipulation device through the first opening into the patient tocontact the spine in a first direction that is transverse to the coronalplane of the patient, the contact of the first manipulation device tothe spine including fixed engagement of the first manipulation device toa first vertebral body; inserting a second manipulation device throughthe second opening into the patient to contact the spine in a seconddirection that is transverse to the sagittal plane of the patient, thecontact of the second manipulation device to the spine including fixedengagement of the second manipulation device to a second vertebral body;and manipulating the first and second manipulation devices to move thefirst vertebral body and the second vertebral body relative to oneanother; wherein the first and second openings are accessiblesimultaneously.
 2. The method of claim 1, wherein the first opening intothe patient affords a substantially posterior approach to the spine, andthe second opening into the patient affords a substantially lateralapproach to the spine.
 3. The method of claim 2, wherein thesubstantially posterior approach to the spine affords the firstinsertion direction to be substantially perpendicular to the coronalplane of the patient, and the substantially lateral approach to thespine affords the second insertion direction to be substantiallyperpendicular to the sagittal plane of the patient.
 4. The method ofclaim 2, wherein the substantially posterior approach affords the firstinsertion direction to be from 45 degrees to −45 degrees with respect tothe sagittal plane, and the substantially lateral approach affords thesecond insertion direction to be from 45 degrees to −45 degrees withrespect to the coronal plane.
 5. The method of claim 1, wherein thefirst direction is also at least partially transverse to the sagittalplane and the second direction is also at least partially transverse tothe coronal plane.
 6. The method of claim 1, further comprisinginserting a third manipulation device through the first opening tofixedly engage the second vertebral body, and manipulating at least thethird manipulation device and one of the first and second manipulationdevices to move the first vertebral body and second vertebral bodyrelative one another.
 7. The method of claim 6, further comprisinginserting a spinal implant between at least portions of the firstvertebral body and the second vertebral body.
 8. The method of claim 1,further comprising inserting a third manipulation device through thesecond opening to fixedly engage the first vertebral body, andmanipulating at least the third manipulation device and one of the firstand second manipulation devices to move the first vertebral body and thesecond vertebral body relative to one another.
 9. The method of claim 8,further comprising inserting a spinal implant between at least portionsof the first vertebral body and the second vertebral body.
 10. Themethod of claim 1, further comprising providing a third opening intoanother posterior portion of the patient, and inserting a thirdmanipulation device through the third opening to fixedly engage thesecond vertebral body, and manipulating at least the third manipulationdevice and one of the first and second manipulation devices to move thefirst vertebral body and the second vertebral body relative to oneanother, wherein the first opening is on a first side of the sagittalplane of the patient, and the third opening is on a second side of thesagittal plane of the patient.
 11. A method for surgically treating thespine of a patient, the method comprising: positioning a patient on asurgical table; providing a first opening into a first posterior portionon a first side of the sagittal plane of the patient; providing a secondopening into a second posterior portion on a second side of the sagittalplane of the patient; inserting a first manipulation device through thefirst opening into the patient to contact the spine in a first directionthat is transverse to the coronal plane of the patient, the contact ofthe first manipulation device to the spine including fixed engagement ofthe first manipulation device to a first vertebral body; inserting asecond manipulation device through the second opening into the patientto contact the spine in a second direction that is transverse to thecoronal plane of the patient, the contact of the second manipulationdevice to the spine including fixed engagement of the secondmanipulation device to a second vertebral body; and manipulating thefirst and second manipulation devices to move the first vertebral bodyand the second vertebral body relative to one another; wherein the firstand second openings are accessible simultaneously.
 12. The method ofclaim 11, wherein the first opening into the patient affords a firstsubstantially posterior approach to the spine, and the second openinginto the patient affords a second substantially posterior approach tothe spine.
 13. The method of claim 11, further comprising inserting athird manipulation device through the first opening to fixedly engagethe second vertebral body, and manipulating at least the thirdmanipulation device and one of the first and second manipulation devicesto move the first vertebral body and second vertebral body relative toone another.
 14. The method of claim 13, further comprising inserting aspinal implant between at least portions of the first vertebral body andthe second vertebral body.
 15. The method of claim 11, furthercomprising providing a third opening into a lateral portion of thepatient, inserting a third manipulation device through the third openingto fixedly engage one of the first vertebral body and the secondvertebral body, and manipulating at least the third manipulation deviceand one of the first and second manipulation devices to move the firstvertebral body and the second vertebral body relative to one another.16. The method of claim 15, further comprising inserting a spinalimplant between at least portions of the first vertebral body and thesecond vertebral body.
 17. A method for surgically treating the spine ofa patient, the method comprising: positioning a patient on a surgicaltable; providing a first opening into a first posterior portion on afirst side of the sagittal plane of the patient; providing a secondopening into a second posterior portion on a second side of the sagittalplane of the patient; providing a third opening into a lateral portionof the patient; inserting a first manipulation device through the firstopening into the patient to contact the spine in a first direction thatis transverse to the coronal plane of the patient, the contact of thefirst manipulation device to the spine including fixed engagement of thefirst manipulation device to one of a first vertebral body and a secondvertebral body; inserting a second manipulation device through thesecond opening into the patient to contact the spine in a seconddirection that is transverse to the coronal plane of the patient, thecontact of the second manipulation device to the spine including fixedengagement of the second manipulation device to one of the firstvertebral body and the second vertebral body; inserting a thirdmanipulation device through the third opening into the patient tocontact the spine in a first direction that is transverse to thesagittal plane of the patient, the contact of the third manipulationdevice to the spine including fixed engagement of the third manipulationdevice to one of the first vertebral body and the second vertebral body;manipulating the first, second, and third manipulation devices to movethe first vertebral body and the second vertebral body relative to oneanother; wherein at least two of the first, second, and third openingsare accessible simultaneously.
 18. The method of claim 17, wherein thefirst opening into the patient affords a first substantially posteriorapproach to the spine, the second opening into the patient affords asecond substantially posterior approach to the spine, and the thirdopening affords a substantially lateral approach to the spine.
 19. Themethod of claim 17, further comprising inserting a fourth manipulationdevice through the third opening into the lateral portion of the patientto fixedly engage the other of the first vertebral body and the secondvertebral body, manipulating at least the fourth manipulation device andat least one of the first, second, and third manipulation devices tomove the first vertebral body and the second vertebral body relative toone another.
 20. The method of claim 19, further comprising inserting afifth manipulation device through one of the first opening and thesecond opening to fixedly engage one of the first vertebral body and thesecond vertebral body, manipulating the fifth manipulation device and atleast one of the first, second, third, and fourth manipulation devicesto move the first vertebral body and the second vertebral body relativeto one another.